Serial echocardiographic and clinical evaluation of valvular regurgitation before, during, and after treatment with fenfluramine or dexfenfluramine and mazindol or phentermine

Dilated Cardiomyopathy: Beware of Diet Drugs Slimming the Heart

There have been rare reports of dilated cardiomyopathy from chronic use of phentermine/topiramate, although very limited data are available. Phentermine is an atypical amphetamine analog that has been contraindicated in patients with a history of cardiovascular disease. We present a case of nonischemic dilated cardiomyopathy in the setting of chronic phentermine/topiramate use, which is the most likely cause of her dilated cardiomyopathy.

Update on the Treatment of Idiopathic Hypersomnia

Purpose of Review

Idiopathic hypersomnia is an incapacitating disorder with a profound impact on daytime performance and quality of life. The most commonly used treatment modalities are lifestyle advice and pharmacological therapy. We present an update on the evidence concerning treatment options for idiopathic hypersomnia.

Recent Findings

Evidence for non-pharmacological interventions is lacking; improvement in symptoms on introducing these interventions is often less pronounced than in narcolepsy. Additional pharmacological treatment is therefore usually initiated. The few treatment studies that have been performed are hampered by small sample sizes and the use of variable and often insufficiently validated outcome parameters for the whole spectrum of idiopathic hypersomnia symptoms.

Conclusion

Evidence on treatment is scarce. Since the efficacy of modafinil is consistently described and there is much experience with this substance, it is reasonable to start with modafinil as a first choice treatment. Methylphenidate and dexamphetamine are good alternatives. In the future, newer drugs such as sodium oxybate, pitolisant, and solriamfetol might be authorized for use in idiopathic hypersomnia.

Drugs Used in Narcolepsy and Other Hypersomnias

Narcolepsy and idiopathic hypersomnia cannot be cured; all available treatments are symptomatic. It is of paramount importance for patients, and their relatives, to be informed about the consequences of these chronic diseases and to become ready to accept the consequences of the diagnosis before starting any treatment. This facilitates the implementation of behavioral modifications and the proper use of medication to decrease the disease burden. A supportive social environment (eg, family members, friends, employer, colleagues, and patient support groups) is instrumental. Current treatment options are discussed with a focus on pharmacologic treatment, including future directions.

Cardiovascular safety of low-dose fenfluramine in Dravet syndrome: a review of its benefit-risk profile in a new patient population

OBJECTIVE

Dravet syndrome (DS) is a rare, treatment-resistant epilepsy syndrome for which current treatment regimens are often ineffective. Fenfluramine is currently in development for treatment of DS, based on reports in the 1980s and 1990s of its anti-epileptic activity in pediatric patients with intractable epilepsy. However, fenfluramine was withdrawn from global markets in 1997 following reports of its association with pulmonary hypertension and heart valve disease in adult patients treated for obesity. This review was conducted to assess cardiac safety of fenfluramine when used at lower doses for treatment of DS.

METHODS

Pubmed was searched for clinical studies of fenfluramine in obese adults who reported incidence of heart valve disease. These data were reviewed against published results from Belgian patients with DS who have been treated with low-dose fenfluramine for up to 28 years.

RESULTS

Nine controlled studies of fenfluramine and related compounds (dexfenfluramine and/or phentermine) which assessed incidence and severity of cardiac valve disease in 3,268 treated patients and 2,017 control subjects have been reported. Mild or greater aortic valve regurgitation was found in 9.6% of treated patients compared with 3.9% of control subjects, and moderate or greater mitral valve regurgitation was found in 3.1% of treated patients and 2.5% of control subjects. Nineteen DS patients have been treated for up to 28 years with 10-20 mg/day fenfluramine, with no clinical signs or symptoms of cardiac valve disease or pulmonary hypertension. Slight and clinically unimportant changes in valve structure have been seen on echocardiography in five patients at some time during the observation period.

CONCLUSIONS

A different benefit-risk relationship appears to be emerging when fenfluramine is used at low doses for extended periods in young patients with DS. Continued cardiac assessments during ongoing Phase 3 clinical trials will provide additional safety information for this potential new and effective treatment.

Effects of lorcaserin on pre-existing valvulopathy: A pooled analysis of phase 3 trials

OBJECTIVE

To evaluate the effects of lorcaserin in patients with pre-existing Food and Drug Administration (FDA)-defined valvulopathy.

METHODS

This is a pooled, post hoc analysis of three Phase 3 studies. BLOOM and BLOSSOM patients were 18 to 65 years of age without diabetes and with a body mass index (BMI) of 27 to 29.9 kg/m² and ≥1 weight-related comorbidity or a BMI of 30 to 45 kg/m² . BLOOM-DM patients had a BMI of 27 to 45 kg/m² and type 2 diabetes. Patients were treated with placebo, lorcaserin 10 mg once daily, or lorcaserin 10 mg twice daily. Serial echocardiographs were obtained at baseline and every 6 months.

RESULTS

Included patients (N = 169) had FDA-defined valvulopathy at baseline and a week 52 echocardiogram. At week 52, 35.5% and 52.7% of patients experienced changes from baseline in aortic and mitral regurgitation, respectively. Numerically greater proportions of patients taking lorcaserin versus placebo had decreases in aortic (33.0% vs. 28.3%) or mitral (41.3% vs. 36.7%) regurgitation. Fewer patients taking lorcaserin versus placebo had increases in aortic (2.8% vs. 6.7%) or mitral (8.3% vs. 21.7%) regurgitation. No adverse event-related discontinuation was due to a valve problem.

CONCLUSIONS

These data suggest that lorcaserin does not adversely affect valvular disease in patients with pre-existing FDA-defined valvulopathy.

Effect of Coleus forskohlii extract on cafeteria diet-induced obesity in rats

BACKGROUND

Obesity is a metabolic disorder that can lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance and also increases the risk of coronary heart disease, ischemic stroke and type 2 diabetes mellitus. This study was designed to determine the effect of Coleus forskohlii on obesity and associated metabolic changes in rats fed with cafeteria diet.

OBJECTIVE

The aim of this study was to evaluate antiobesogenic and metabolic benefits of C. forskohlii in cafeteria diet induced obesity rat model.

MATERIALS AND METHODS

RATS WERE RANDOMLY DIVIDED INTO FIVE GROUPS OF SIX ANIMALS IN EACH GROUP AND AS FOLLOWS: Normal pellet diet group; cafeteria diet group; cafeteria diet followed by 50 mg/kg/d Coleus forskohlii extract (CFE), 100 mg/kg/d CFE and 45 mg/kg/d orlistat groups, respectively. Indicators of obesity such as food intake, body weight and alteration in serum lipid profiles were studied.

RESULTS

Feeding of cafeteria diet induced obesity in rats. Administration of CFE significantly halted increase in food intake and weight gain associated with cafeteria diet. Development of dyslipidemia was also significantly inhibited.

CONCLUSION

The observed effects validate that supplementation of CFE with cafeteria diet could curb the appetite and mitigate the development of dyslipidemia.

Valvular heart disease in patients exposed to pergolide: insights from the clinical presentation

PURPOSE

The aim of this study was to determine whether the presence of symptoms would aid in the detection of valvular heart disease (VHD) in those exposed to pergolide.

METHODS

Utilizing a prospective, cross-sectional study design, patients with an exposure to pergolide were asked regarding the presence or absence of chest pain, shortness of breath or lower extremity edema through a questionnaire. Echocardiograms were obtained on the same day as the questionnaire and were blinded to all staff involved in the study. The sensitivity, specificity, positive and negative predictive value of the reported symptoms towards the outcome moderate or severe valvular regurgitation were obtained. Using the area under the receiver-operating characteristic curve, we also ascertained whether a relationship existed between symptoms, pergolide dose and presence of VHD. To understand the associations between symptoms and echocardiographic covariates, a logistic regression analysis was performed adjusted for age and gender.

RESULTS

The sensitivity, specificity, positive and negative predictive value of symptom presentation and total dose was sufficiently low that it did not aid in the determination whether significant valvular regurgitation was present. Multivariable analysis noted a significant association with indexed left atrial volume (p = 0.011), estimated pulmonary artery pressure (p = 0.047) and shortness of breath.

CONCLUSIONS

The presence or absence of symptoms does not help guide whether valvular regurgitation is present or absent in individuals exposed to pergolide. Therefore, echocardiography is needed to confirm or refute pergolide-associated VHD.

Hypolipidemic and weight reducing activity of the ethanolic extract of Tamarindus indica fruit pulp in cafeteria diet- and sulpiride-induced obese rats

Objectives:

To investigate the effect of ethanolic extract of fruit pulp of Tamarindus indica Linn. (Family: Caesalpiniaceae) on obesity in rats using cafeteria diet-induced obesity and antipsychotic drug (sulpiride)-induced obesity.

Materials and Methods:

Cafeteria dietwas administered for 40 successive days to male Wistar rats and sulpiride (20 mg/kg, i.p.) was administered for 28 successive days to female Wistar rats. In separate groups of animals, the ethanolic extract (50 and 100 mg/kg p.o.) of Tamarindus indica fruit was administered along with cafeteria diet for 40 successive days to Wistar male rats and along with sulpiride for 28 successive days to Wistar female rats.

Results:

Cafeteria diet alone significantly increased body weight, serum total cholesterol, triglycerides, and glucose levels and decreased HDL cholesterol in male rats as compared to control. Sulpiride per se significantly increased the levels of glucose, triglycerides, cholesterol and there was no significant effect on HDL-cholesterol in female rats as compared to control. Ethanolic extract showed a significant decrease in body weight, serum cholesterol, and triglycerides and a significant increase in HDL-cholesterol in cafeteria diet- and sulpiride-induced obese rats as compared to their respective control groups.

Conclusions:

Thus, the ethanolic extract of Tamarindus indica fruit pulp showed a significant weight-reducing and hypolipidemic activity in cafeteria diet- and sulpiride-induced obese rats.

Current and future therapeutic approaches in narcolepsy

Narcolepsy with cataplexy (NC) is a disabling orphan sleep disorder characterized by excessive daytime sleepiness, cataplexy and other dissociated manifestations of rapid eye movement sleep (hypnagogic hallucinations and sleep paralysis), as well as frequent movement and awakening during night-time sleep. In this article, we will describe the main symptoms and the current and future treatments of NC. Pathophysiological studies have shown that NC is caused by the early loss of neurons in the hypothalamus that produce hypocretin/orexin, a wakefulness-associated neurotransmitter present in cerebrospinal fluid. The cause of neural loss could be autoimmune since most patients have the human leukocyte antigen DQB1*0602 allele that predisposes individuals to NC. The treatment of narcolepsy has evolved over the past few years with the widespread use of modafinil for daytime sleepiness, antidepressants for cataplexy and γ-hydroxybutyrate (sodium oxybate) for both symptoms. Potential development of new wake-promoting drugs, anticataplectic medications, slow-wave sleep-enhancing treatments, hypocretin-replacement therapy and immunotherapy at early stages of the disease needs to be evaluated in the near future.

Combination drugs for treating obesity

Although obesity is a chronic disease like hypertension and diabetes, obesity is not treated with drug combinations as are other chronic diseases. This is because orlistat and sibutramine, the two drugs approved for long-term treatment of obesity, do not result in additive weight loss when combined. This article discusses the history of combination drug therapy for treating obesity, the lessons learned from that experience, and describes the drug combinations now in development. One combination of two standardized dietary herbal supplements that result in clinically significant weight loss is also described. Obesity is poised to enter the era of combination drug therapy, as is now the routine in the treatment of other chronic diseases like hypertension and diabetes. The advent of combination drug therapy for obesity treatment offers hope for increasing the efficacy of obesity pharmacotherapy.

Appetite suppressants, cardiac valve disease and combination pharmacotherapy

The prevalence of obesity in the United States is a major health problem associated with significant morbidity, mortality, and economic burden. Although obesity and drug addiction are typically considered distinct clinical entities, both diseases involve dysregulation of biogenic amine neuron systems in the brain. Thus, research efforts to develop medications for treating drug addiction can contribute insights into the pharmacotherapy for obesity. Here, we review the neurochemical mechanisms of selected stimulant medications used in the treatment of obesity and issues related to fenfluramine-associated cardiac valvulopathy. In particular, we discuss the evidence that cardiac valve disease involves activation of mitogenic serotonin 2B (5-HT2B) receptors by norfenfluramine, the major metabolite of fenfluramine. Advances in medication discovery suggest that novel molecular entities that target 2 different neurochemical mechanisms, that is, "combination pharmacotherapy," will yield efficacious antiobesity medications with reduced adverse side effects.

Comparison of adverse events between the Bryan artificial cervical disc and anterior cervical arthrodesis

STUDY DESIGN

Randomized controlled study.

OBJECTIVE

To compare the rates of adverse events associated with disc arthroplasty versus those of anterior cervical discectomy and arthrodesis with allograft and plate.

SUMMARY OF BACKGROUND DATA

Cervical disc arthroplasty as a substitute for fusion has been developed to maintain motion and, theoretically, prevent adjacent segment degeneration. Currently, cervical arthroplasty devices are undergoing clinical testing for safety and efficacy. The evaluation of safety is performed by critical analysis of all adverse occurrences following surgery to determine if the new device has a beneficial risk profile for the patient.

METHODS

Adverse events associated with Bryan Disc arthroplasty and arthrodesis were compared in a prospective randomized study. Four hundred sixty-three (463) patients having cervical radiculopathy and or myelopathy at a single level were treated at 31 sites. A total of 242 patients received the disc and 221 patients had anterior cervical discectomy and fusion. All patients were evaluated before surgery and at 1.5, 3, 6, 12, and 24 months after surgery. Adverse events were recorded concurrently and categorized by severity and as medically or surgically related.

RESULTS

No differences in overall medical events occurred between groups. Surgically related events occurred more frequently in the investigational group secondary to more complaints of postoperative dysphagia and late medical events occurred more frequently in the investigational patients. However, the more severe World Health Organization Grade 3 and 4 events occurred more frequently in the arthrodesis patients related to treatment of pseudarthrosis and persistent symptoms. Significantly, more cervical spine reoperations occurred in the fusion group. Only one spinal cord injury occurred and it was in the arthrodesis group and no patients had deep infection or death related to either procedure.

CONCLUSION

Bryan cervical disc replacement and anterior cervical fusion are both safe procedures with a low incidence of significant adverse events related to the procedure. Statistically, more serious adverse events and reoperations occurred in the fusion group while a greater number of less serious surgically related events were seen in the investigational group.

Narcolepsy with cataplexy

Narcolepsy with cataplexy is a disabling sleep disorder affecting 0.02% of adults worldwide. It is characterised by severe, irresistible daytime sleepiness and sudden loss of muscle tone (cataplexy), and can be associated with sleep-onset or sleep-offset paralysis and hallucinations, frequent movement and awakening during sleep, and weight gain. Sleep monitoring during night and day shows rapid sleep onset and abnormal, shortened rapid-eye-movement sleep latencies. The onset of narcolepsy with cataplexy is usually during teenage and young adulthood and persists throughout the lifetime. Pathophysiological studies have shown that the disease is caused by the early loss of neurons in the hypothalamus that produce hypocretin, a wakefulness-associated neurotransmitter present in cerebrospinal fluid. The cause of neural loss could be autoimmune since most patients have the HLA DQB1*0602 allele that predisposes individuals to the disorder. Treatment is with stimulant drugs to suppress daytime sleepiness, antidepressants for cataplexy, and gamma hydroxybutyrate for both symptoms. Because narcolepsy is an under-recognised disease, it is important that general practitioners and other primary health-care workers identify abnormal daytime sleepiness early.

Impact of weight-loss medications on the cardiovascular system: focus on current and future anti-obesity drugs

Overweight and obesity have been rising dramatically worldwide and are associated with numerous co-morbidities such as cardiovascular disease (CVD), type 2 diabetes mellitus, hypertension, certain cancers, and sleep apnea. In fact, obesity is an independent risk factor for CVD and CVD risks have also been documented in obese children. The majority of overweight and obese patients who achieve a significant short-term weight loss do not maintain their lower bodyweight in the long term. This may be due to a lack of intensive counseling and support from a facilitating environment including dedicated healthcare professionals such as nutritionists, kinesiologists, and behavior specialists. As a result, there has been a considerable focus on the role of adjunctive therapy such as pharmacotherapy for long-term weight loss and weight maintenance. Beyond an unfavorable risk factor profile, overweight and obesity also impact upon heart structure and function. Since the beginning, the quest for weight loss drugs has encountered warnings from regulatory agencies and the withdrawal from the market of efficient but unsafe medications. Fenfluramine was withdrawn from the market because of unacceptable pulmonary and cardiac adverse effects. Nevertheless, there is extensive research directed at the development of new anti-obesity compounds. The effect of these molecules on CVD risk factors has been studied and reported but information regarding their impact on the cardiovascular system is sparse. Thus, instead of looking at the benefit of weight loss on metabolism and risk factor management, this article discusses the impact of weight loss medications on the cardiovascular system. The potential interaction of available and potential new weight loss drugs with heart function and structure is reviewed.

Comparison of combinations of drugs for treatment of obesity: body weight and echocardiographic status

BACKGROUND

Obesity treatment with single drugs produces weight losses of about 8-10% of initial body weight. Few studies of combinations of drugs for treating obesity have been published. The combination of phentermine, an adrenergic agent, and fenfluramine, a serotonergic agent, (phen-fen) produced weight losses of about 15% of initial body weight. Fenfluramine is no longer available because it was associated with cardiac valve lesions. Phentermine-fluoxetine (phen-flu) has been proposed as an alternative for phen-fen.

OBJECTIVE

To compare the efficacy of treatment and prevalence of cardiac valve abnormalities on phen-flu vs phen-fen.

DESIGN

Retrospective chart review of all patients treated for at least 3 months with phen-flu (N=97) to a random sample of patients treated with phen-fen (N=98) in the Clinical Nutrition Clinic at the University of Wisconsin. Comparison of echocardiograms in all patients treated solely with phen-flu (N=21) to a random sample of patients treated with phen-fen (N=47), and to a group of subjects never treated with obesity drugs (N=26).

RESULTS

With last observation carried forward analysis (LOCF), at 6 months of treatment the phen-fen patients lost 12.6+/-0.6% of baseline weight and phen-flu patients lost 9.0+/-0.6% (P<0.001). With completers analysis, there were no significant differences in weight loss as a percent of baseline weight at 6 months (14.4+/-0.6 vs 13.3+/-0.9%). LOCF decreases in body mass index (BMI) at 6 months were -5.3 and -3.6 kg/m(2) for phen-fen and phen-flu, respectively (P<0.001), and 6.2+/-0.3 vs 5.4+/-0.4 kg/m(2), respectively, for the completers analysis (P - NS). Dropout rate at 6 months was higher in phen-flu subjects (44 vs 28%). In subjects without atherosclerosis of valves (presumably pre-existing), cardiac valve lesions occurred in eight of 38 phen-fen subjects and in none of 15 phen-flu subjects or 25 control subjects who had not been treated with drugs.

CONCLUSIONS

The combination of phentermine and fluoxetine was not as effective as phen-fen, but was not associated with cardiac valve lesions. Longer term, larger scale studies of phen-flu are warranted.

Safety of drug therapies used for weight loss and treatment of obesity

Some of the medications used for weight loss in the management of obesity have been associated with unacceptable morbidity and mortality. Safety concerns have led to the withdrawal of aminorex, followed by the fenfluramines in 1997, and phenylpropanolamine (norephedrine) in 2000. Aminorex was associated with an increased prevalence of primary pulmonary hypertension (PPH), fenfluramines with an increased prevalence of PPH and valvulopathy, and phenylpropanolamine with an increased risk of haemorrhagic stroke. Several studies have investigated the safety of the fenfluramines, yet the benefit-risk profile has not been conclusively quantified. This is due to several deficiencies in the published studies, including a lack of data on the baseline prevalences of comorbid conditions in obese subjects, and potential confounders and biases in the study designs. Although several studies and systematic reviews support an increased risk of PPH and valvulopathy in patients who have taken fenfluramines, without knowledge of the background prevalence it is not possible to determine if the exposure preceded the outcome. The population at higher risk of these adverse effects includes those taking higher doses or with a longer duration of exposure to fenfluramines and those with pre-existing cardiac disease or a genetic predisposition. Patients exposed to fenfluramines continue to be monitored, with some follow-up studies indicating no overall worsening in valvulopathy over time. There are limited efficacy and safety data for amfepramone (diethylpropion) and phentermine and their approval for the management of obesity is limited to short-term use. Orlistat and sibutramine are the only currently approved medications for long-term management of obesity. Although the benefit-risk profiles of sibutramine and orlistat appear positive, sibutramine continues to be monitored because of long-term safety concerns. The safety and efficacy of currently approved drug therapies have not been evaluated in children and elderly patient populations and there is limited information in adolescents, whilst the long-term safety of current and potential new drug therapies in adults will require several years of postmarketing surveillance to fully elucidate their adverse effect profiles.

Safety of obesity drugs

The safety of obesity drugs has historically been poor. This and the stigmatisation of obesity in society ensured that a higher standard of safety for obesity drugs must be met. The authors review the safety disasters of obesity drugs that were withdrawn. The authors then review the safety of presently available drugs--benzphetamine, phendimetrazine, diethylpropion, phentermine, sibutramine and orlistat. The safety of rimonabant, a drug with a pending new drug application that has an independent effect on metabolic syndrome, is also reviewed. The authors compare the stage of obesity drug development to that of hypertension in the 1950s. As new and safer drugs with more downstream mechanisms are developed that have independent effects on the cardiovascular risks associated with obesity, third party reimbursement for obesity medicine is likely to improve. This may lead to obesity being treated like hypertension and other chronic diseases with long-term medication. With improved technological tools, the authors believe this process will be more rapid for obesity than it was for hypertension.

Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism

Obesity is becoming a global epidemic in both children and adults. It is associated with numerous comorbidities such as cardiovascular diseases (CVD), type 2 diabetes, hypertension, certain cancers, and sleep apnea/sleep-disordered breathing. In fact, obesity is an independent risk factor for CVD, and CVD risks have also been documented in obese children. Obesity is associated with an increased risk of morbidity and mortality as well as reduced life expectancy. Health service use and medical costs associated with obesity and related diseases have risen dramatically and are expected to continue to rise. Besides an altered metabolic profile, a variety of adaptations/alterations in cardiac structure and function occur in the individual as adipose tissue accumulates in excess amounts, even in the absence of comorbidities. Hence, obesity may affect the heart through its influence on known risk factors such as dyslipidemia, hypertension, glucose intolerance, inflammatory markers, obstructive sleep apnea/hypoventilation, and the prothrombotic state, in addition to as-yet-unrecognized mechanisms. On the whole, overweight and obesity predispose to or are associated with numerous cardiac complications such as coronary heart disease, heart failure, and sudden death because of their impact on the cardiovascular system. The pathophysiology of these entities that are linked to obesity will be discussed. However, the cardiovascular clinical evaluation of obese patients may be limited because of the morphology of the individual. In this statement, we review the available evidence of the impact of obesity on CVD with emphasis on the evaluation of cardiac structure and function in obese patients and the effect of weight loss on the cardiovascular system.

The UCSD Statin Study: a randomized controlled trial assessing the impact of statins on selected noncardiac outcomes

There has been persistent controversy regarding possible favorable or adverse effects of statins or of cholesterol reduction on cognition, mood and behavior (including aggressive or violent behavior), muscle function, and quality of life. The UCSD Statin Study seeks to ascertain the beneficial or adverse effects of statin cholesterol-lowering drugs on a set of noncardiac endpoints, including cognition, behavior, and serotonin biochemistry. The study will enroll 1000 subjects (minimum 20% female) of mixed ethnicity from San Diego. Subjects must be age 20 and older, postmenopausal if female, without known cardiovascular disease or diabetes, and with LDL-cholesterol between 115 and 190 mg/dl. Subjects will be randomized to a double-blind, placebo-controlled trial with assignment 1/3, 1/3, 1/3 to placebo, simvastatin 20 mg, or pravastatin 40 mg (equipotent LDL-cholesterol-lowering doses for drug arms with simvastatin and pravastatin chosen to represent the extremes of the lipophilicity spectrum) for 6 months of treatment followed by 2 months postcessation follow-up. Primary outcomes are cognition (cognitive battery), irritability/aggression (behavior measure), and serotonin (gauged by whole blood serotonin), assessed as the difference between baseline and 6 months, judging combined statin groups vs. placebo. Secondary outcomes include mood (CES-D and Wakefield depression inventory), quality of life (SF-12V), sleep (Leeds sleep scale, modified), and secondary aggression measures (Conflict Tactics Scale; Overt Aggression Scale, Modified). Cardiovascular reactivity will be examined in a 10% subset. As additional secondary endpoints, primary and selected secondary outcomes will be assessed by statin assignment (lipophilic simvastatin vs. hydrophilic pravastatin). "Reversibility" of changes, if any, at 2 months postcessation will be determined. If effects (favorable or unfavorable) are identified, we will seek to ascertain whether there are baseline variables that predict who will be most susceptible to these favorable or adverse noncardiac effects (i.e., effect modification).

Pharmacological management of narcolepsy

Narcolepsy is a disabling disorder characterised by excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, sleep paralysis and disturbed nocturnal sleep. Traditionally, a wide variety of substances are used in the symptomatic pharmacological treatment of narcolepsy. Several generally more-tolerated substances have been added to the therapeutic repertoire after extensive testing in large patient populations during recent years. This review addresses the state-of-the-art knowledge about the pharmacological treatment of narcolepsy along with the personal view of the authors. The recent discovery that narcolepsy is caused by deficient hypocretin (orexin) transmission opens a perspective on causal therapy.

Risk of valvular heart disease associated with use of fenfluramine

BACKGROUND

Estimates of excess risk of valvular heart disease among prior users of fenfluramine and dexfenfluramine have varied widely. Two major forms of bias appear to contribute to this variability and also result in a systematic under-estimation of risk. The first, a form of nondifferential misclassification, is the result of including background, prevalent cases among both exposed and unexposed persons in calculations of risk. The second bias results from not considering the relatively short duration of exposure to drugs.

METHODS

We examined data from all available echocardiographic studies reporting the prevalence of aortic regurgitation (AR) and mitral regurgitation (MR) among persons exposed to fenfluramine or dexfenfluramine and a suitable control group. We also included one study in which previously existing AR or MR had been excluded. We corrected for background prevalent cases, estimated incidence rates in unexposed persons, and performed a person-years analysis of apparent incidence rates based on exposure time to provide an unbiased estimate of relative risk.

RESULTS

Appearance of new AR was strongly related to duration of exposure (R2 = 0.75, p < 0.0001). The summary relative risk for mild or greater AR was 19.6 (95% CI 16.3-23.5, p < 0.00001); for moderate or greater MR it was 5.9 (95% CI 4.0-8.6, p < 0.00001).

CONCLUSION

These findings provide strong support for the view that fenfluramine and dexfenfluramine are potent causal factors in the development of both aortic and mitral valvular heart disease.

Quantitative analysis of human heart valves: does anorexigen exposure produce a distinctive morphological lesion?

The need for more detail regarding the clinical and morphological features of human heart valves has become evident due to recent controversy regarding anorexigen-associated valvular dysfunction. In the present study, we used quantitative digital image analysis of geometric and compositional features to compare the histopathology of cardiac valves excised from patients treated with anorexigens as compared to normal, floppy, rheumatic and carcinoid valves. Anorexigen-exposed valves had the greatest number of onlays/valve (P<.0001), while rheumatic valves showed the greatest average onlay size and thickness of the comparison groups studied (P=.01). The valve onlays from anorexigen-exposed, carcinoid and floppy valves contained a greater percentage of glycosaminoglycans (GAGs) as compared to normal and rheumatic valves (P=.01). The anorexigen-exposed valve propers contained more GAGs than any other comparison group (P=.02). Vessels were prominent in both onlay and valve proper regions of carcinoid valves, in the anorexigen-exposed valve onlays and in rheumatic valve propers. Thus, the number of onlays, their size, the degree of GAG deposition, and the presence and location of vessels and leukocytes were important features distinguishing anorexigen-exposed valves from normal valves. Discriminant analyses, based on geometry, color composition or color composition, and vessel and leukocyte counts combined, were able to separate the valves into distinguishable groups. Our findings demonstrate that specific microscopic features can be used to separate anorexigen-associated heart valve lesions from normal valves and valve lesions associated with other pathologies, and suggest that a distinctive pathological process may exist in many anorexigen-exposed valves.

Testing the test: the reliability of echocardiography in the sequential assessment of valvular regurgitation

BACKGROUND AND OBJECTIVE

Substantial variability in serial echocardiographic qualitative assessment of valvular regurgitation may exist. Reader variability is generally well understood, but acquisition variability (portions of variability caused by equipment, sonographers, physiologic changes) has been less frequently assessed, particularly in combination with reader variability. We attempted to determine the relative contributions of acquisition and reader variability as components of total test-retest variability for aortic (AR) and mitral (MR) regurgitation.

METHODS

Outpatient echocardiographic study was done at 2 clinical sites. Twenty-three predominantly obese middle-aged females had 3 echocardiograms, 2 performed 14 +/- 3 days apart and the third performed within 1 to 2 hours of the second. Triplets of echocardiograms were evaluated for change in grade of AR and MR. Medical history, anthropometrics, and blood pressures were obtained.

RESULTS

Average intrareader variability (percentage of reads for which there is within-reader disagreement) was 5.6% for AR and 16.7% for MR. The average total test-retest variability (percentage of reads for which there is disagreement between visits) was 29.0% for AR and 24.6% for MR. The acquisition variability for AR was 23.4% +/- 7.7%; for MR, it was 7.9% +/- 10.2%. A significant predictor of change for AR/MR was the initial grade. Change in diastolic blood pressure was positively associated with change in AR and MR.

CONCLUSIONS

Intrareader agreement was substantial for AR and MR. Components of total test-retest variability found were reader, biological (change in diastolic blood pressure), and regression to the mean. Recommendations for clinical practice include monitoring blood pressure changes and understanding the confidence limits of the clinical test. Test-retest variability and its components should be considered in echocardiography and other diagnostic testing.

Obesity pharmacology: past, present, and future

Over the past several years, the pharmacologic treatment of obesity has undergone changes in safety, efficacy, and therapeutic targeting. The prevalence of cardiac valvulopathy associated with treatment with phentermine, fenfluramine, and dexfenfluramine is now becoming clarified with the publication of longer-term studies. Phenylpropanolamine, a well-known over-the-counter appetite suppressant, was recently removed from the market in the United States because of an increased risk of hemorrhagic stroke in women. In contrast, two currently approved medications, sibutramine and orlistat, have been shown to be safe and moderately effective for weight loss with documented beneficial effects on cardiovascular risk factors. Three other drugs, bupropion, topiramate, and ciliary neurotrophic factor, are undergoing clinical trials for obesity based on empirical observations. Most promising are the advances in genetics and molecular biology that are beginning to elucidate new targets for controlling appetite and energy utilization. These therapeutic agents will likely herald a second generation of anti-obesity medications over the next decade.

Drug treatment of obesity

At present only two drugs are approved for long-term treatment of obesity. Sibutramine inhibits the reuptake of serotonin and norepinephrine. In clinical trials it produces a dose-dependent 5-10% decrease in body weight. Its side effects include dry mouth, insomnia, asthenia, and constipation. In addition, sibutramine produces a small increase in blood pressure and pulse that is a contraindication to the use of this drug in some individuals with heart disease. Xenical is the other drug approved for long-term use in the treatment of obesity. It works by blocking lipase and thus increasing the fecal loss of triglyceride. One valuable consequence of this mechanism of action is the reduction of serum cholesterol that averages about 5% more than can be accounted for by weight loss alone. In clinical trials it produces a 5-10% loss of weight. Its side effects are entirely due to undigested fat in the intestine that can lead to increased frequency and change in the character of stools. It can also lower fat-soluble vitamins. The ingestion of a vitamin supplement before bedtime is a reasonable treatment strategy. The effect on weight loss during long-term trials with these two drugs is shown in Figs 7 and 8 above. Also in this figure is data on phentermine used in trials of six months or more. Although there were differences in mean weight losses with these drugs, when the placebo effect was taken into account they all had a surprisingly similar magnitude of weight loss.

Narcolepsy: clinical features, new pathophysiologic insights, and future perspectives

Narcolepsy is characterized by excessive daytime sleepiness and abnormal manifestations of rapid eye movement sleep such as cataplexy. The authors review the clinical features of narcolepsy, including epidemiology, symptoms, diagnosis, and treatment, in detail. Recent findings show that a loss of hypocretin-producing neurons lies at the root of the signs and symptoms of narcolepsy. The authors review the current state of knowledge on hypocretin anatomy, physiology, and function with special emphasis on the research regarding the hypocretin deficiency in narcolepsy, which may also explain associated features of the disorder, such as obesity. Lastly, they discuss some future perspectives for research into the pathophysiology of sleep/wake disorders, and the potential impact of the established hypocretin deficiency on the diagnosis and treatment of narcolepsy.

Psychological and behavioral predictors of weight loss during drug treatment for obesity

OBJECTIVE

This study investigated whether baseline eating behavior, emotions, and body image were significant predictors of change in body mass index (BMI) over 6 month and 12 month time intervals for individuals enrolled in a weight loss program that combined appetite suppressant medications and behavior therapy for obesity.

METHOD

Participants were asked to complete self-report questionnaires at baseline, 6 months, and 12 months. In addition, their height and weight were measured and they were administered a body image assessment procedure at each time interval.

RESULTS

At baseline, perceived hunger, dietary restraint, current body size, and trait anxiety were important components in a model for prediction of weight loss at 6 months. Perceived hunger, dietary restraint, and current body size as measured at baseline were important components in the prediction of weight loss at 12 months. These predictive variables, together with gender and initial BMI, accounted for 48.6% of the variance in weight loss at 6 months and 51.7% of the variance in weight loss at 12 months.

DISCUSSION

These findings suggest that scores on certain paper and pencil tests may be useful as predictors of success or failure for individuals entering a weight loss program using pharmacological and behavioral interventions.

A concise review on the therapeutics of obesity

Drugs to treat obesity can be divided into three groups: those that reduce food intake; those that alter metabolism; and those that increase thermogenesis. Monoamines acting on noradrenergic receptors, serotonin receptors, dopamine receptors, and histamine receptors can reduce food intake. A number of peptides also affect food intake. The noradrenergic drugs phentermine, diethylpropion, mazindol, benzphetamine, and phendimetrazine are approved only for short-term use. Sibutramine, a norepinephrine-serotonin reuptake inhibitor, is approved for long-term use. Orlistat inhibits pancreatic lipase and can block 30% of the triacylglycerol hydrolysis in subjects eating a 30% fat diet. The only thermogenic drug combination that has been tested is ephedrine and caffeine, but this treatment has not been approved by regulatory agencies. In clinical trials other drugs that may modulate peptide-feeding systems are being developed.

Medicinal strategies in the treatment of obesity

When prevention fails, medicinal treatment of obesity may become a necessity. Any strategic medicinal development must recognize that obesity is a chronic, stigmatized and costly disease that is increasing in prevalence. Because obesity can rarely be cured, treatment strategies are effective only as long as they are used, and combined therapy may be more effective than monotherapy. For a drug to have significant impact on body weight it must ultimately reduce energy intake, increase energy expenditure, or both. Currently approved drugs for long-term treatment of obesity include sibutramine, which inhibits food intake, and orlistat, which blocks fat digestion.

Recent progress in obesity pharmacotherapy

Interest in obesity pharmacotherapy is intense, sparked by the public health threat of increases in obesity rates, as well as by increased knowledge of the biology underlying food intake and energy balance. After a hiatus of more than 20 years, three new medications approved by the US Food and Drug Administration for obesity treatment recently reached the marketplace. One of these, dexfenfluramine, has been withdrawn because of fenfluramine's and its isomer's association with valvular regurgitation. Sibutramine, a centrally acting reuptake inhibitor of monoamines, and orlistat, a pancreatic lipase inhibitor, have been approved for long-term obesity treatment. This review covers recent publications documenting clinical trial experience with these two agents and updates the evidence associating dexfenfluramine and fenfluramine with valvulopathy. As obesity rates increase throughout the world and as knowledge expands regarding the biology of obesity, an expansion of pharmacologic options for obesity treatment is certain.

Echocardiographic improvement over time after cessation of use of fenfluramine and phentermine

OBJECTIVE

To determine the echocardiographic changes over time of valvular heart lesions in patients who took the weight loss drugs fenfluramine and phentermine.

SUBJECTS AND METHODS

This prospective cohort study began at the termination of a randomized, double-blind, placebo-controlled weight loss trial of 18 obese women and 13 obese men (mean age, 42 years; mean body mass index, 33.4 kg/m2) who had been assigned randomly to treatment with fenfluramine and phentermine or to placebo. Echocardiograms were obtained at termination of the trial when fenfluramine was withdrawn from the market and 6 months later. They were interpreted independently by 3 cardiologists blinded to treatment assignment and temporal sequence of the echocardiograms. The main outcome measure was the change in drug-related valvular disease over time.

RESULTS

One subject assigned to receive the drugs was lost to follow-up, and 3 subjects who did not meet a weight loss goal of 10 kg crossed over from placebo to drug treatment. Echocardiograms were obtained in 19 subjects who received the drugs and 11 subjects who received placebo, and 6-month follow-up echocardiograms were obtained in 15 subjects who received the drugs and 3 who received placebo. Subjects had taken fenfluramine and phentermine a mean of 41 weeks (range, 8-73 weeks). Five of 19 subjects who received the drugs (26%; 95% confidence interval, 7%-46%) and 1 of 11 who received placebo (9%) (odds ratio, 3.6; 95% confidence interval, 0.4-35.6) had findings that met criteria established for drug-related valvular disease. All 5 subjects (4 women and 1 man) receiving the drugs had mild aortic regurgitation, and 1 also had pulmonary hypertension (estimated pulmonary artery pressure, 59 mm Hg). Six months later, the echocardiographic findings had improved in all 5 subjects (P=.06), and 3 no longer met the criteria for drug-related valvular disease. Pulmonary artery pressures decreased to near normal in the subject with pulmonary hypertension (37 mm Hg). Overall, the echocardiographic valvular features improved in 8 of 15 subjects who received the drugs and had echocardiograms performed at both time periods (P=.008).

CONCLUSIONS

Valvular heart disease did not appear to progress after cessation of use of fenfluramine and phentermine, and echocardiographic valvular features appeared to improve over time.