Michael S. Lauer, MD
Disclaimer: The views expressed here are those of the author and do not necessarily reflect the views of the National Heart, Lung, and Blood Institute or of the Patient-Centered Outcomes Research Institute.
Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0689.
Requests for Single Reprints: Michael S. Lauer, MD, 6701 Rockledge Drive, Room 8128, Bethesda, MD 20892; e-mail, firstname.lastname@example.org.
Author Contributions: Conception and design: M.S. Lauer.
Drafting of the article: M.S. Lauer.
Critical revision of the article for important intellectual content: M.S. Lauer.
Final approval of the article: M.S. Lauer.
Obtaining of funding: M.S. Lauer.
Administrative, technical, or logistic support: M.S. Lauer.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
dhastagir, sheriff d, professor of biochemistry
faculty of Medicine. Benghazi University, Benghazi
April 10, 2012
Apples for obesity will be better than Lemons
An apple a day keeps a doctor away is one saying followed by an aspirin a day keep the coronary artery disease away. Now the need for drugs for obesity control push drug manufacturers and scientists look for a drug that will help obesity prevention. Daedalus effect that every clinical decision carries a risk associated with it. This is true for every clinical situation or therapy. Prudence must prevail over irrational need or corporate culture.
Enrique J., Sanchez-Delgado, Director of Medical Education
Hospital Metropolitano Vivian Pellas, Managua, Nicaragua
April 17, 2012
How to identify cardiovascular risk with obesity drugs before events
How to identify cardiovascular risk with obesity drugs before events
The lesson has been clear with anterior cases of drugs for obesity. If they reduce weight, but produce increases in resting heart rate and/or blood pressure, or produce important cognitive or mood disorders, and more important, if the balance of the PULSE MASS INDEX or the PULSE MASS PRESSURE PRODUCT is not reduced, the continuation of their use should be discouraged.
In the case of rimonabant, I sent a letter to Lancet mentioning the reasons why it should be discontinued, one year before the EMA decided to take it out from the market (the letter was not published then, but latter in the BMJ).
If the Body Mass Index and the Resting Heart Rate, are elevated (the PULSE MASS INDEX), the probability to have a high risk in the Framingham Risk Score, or elevated risk of mortality, is very high (1).
Measure the PULSE MASS PRESSURE PRODUCT (Body Mass Index by Resting Heart Rate by Systolic Blood Pressure). If over 200000 pay attention, if over 240000, the probability of a high cardiovascular risk is clearly elevated and the obesity drug, Qnexa or any other, will probably produce a higher incidence of cardiovascular events.
In this context, the use of weekly injections of exenatide in obese diabetic or pre-diabetic patients looks promising.
Prof. Enrique Sanchez-Delgado, MD Internal Medicine- Clinical Pharmacology Hospital Metropolitano Vivian Pellas Managua, Nicaragua
Ref. 1. E. Sanchez-Delgado. Lancet.Volume 353, Number 9156,13 March 1999
Franz H. Messerli,† Sripal Bangalore,* Seth Uretsky†
† St. Luke’s Roosevelt Hospital, Columbia University College of Physicians and Surgeons, New York, New York. * Cardiac Catheterization Laboratory, The Leon H. Charney Division of Cardiology, New York
August 9, 2012
Letter to the Editor: Lemons for obesity.
In his eloquent editorial Dr. Lauer (1) criticizes physician’s “excess reliance on surrogates.” because it not uncommonly leads to surrogate failure. Drugs seem to do good things like reduce blood pressure and glycemia or increase HDL cholesterol but fail to reduce morbidity and mortality or worse, may even hasten demise. From a strictly cardiocentric point of view indexes of overweight and obesity can be considered as surrogate endpoints and as such are occasionally prone to failure (2). However, obesity cannot be put on an equal footing with the above completely asymptomatic surrogate endpoints. For most patients HDL cholesterol is a somewhat esoteric concept making for interesting topic at a cocktail party. In contrast, obesity remains a major opprobrium in our society to the extent that some patients gladly would trade a few months of life expectancy for a more slender body habitus. Regardless of whether and how it affects cardiovascular risk, a weight loss of 10% as was observed with Qnexa can be uplifting and greatly improve quality of life in an obese patient (3). In contrast we have no way of knowing what an increase of average heart rate by 1.5 bpm as was also seen with Qnexa will engender in terms of life expectancy. Heart rate does not always inversely correlate with cardiovascular morbidity and mortality and just as are other surrogates, may be prone to failure. (4). Unfortunately the meager outcome data in the NDA of Qnexa with only 12 outcome events do not allow us to establish a clear risk benefit ratio. Thus as Dr. Lauer appropriately states, we are at this juncture not sure whether we are dealing with a peach or a lemon. Given such uncertainty we should perhaps err on the cautious side and remember Hemingway’s dictum on the heart (5): “It is just a muscle. Only it is the main muscle. It works as perfectly as a Rolex Oyster Perpetual. The trouble is you cannot send it to the Rolex representative when it goes wrong. When it stops, you just don’t know the time. You’re dead”. Drs. Messerli, Bangalore and Uretsky report no potential conflicts of interest.
1. Lauer MS. Lemons for obesity. Ann Intern Med. 2012 Jul 17;157(2):139-40.
2. Uretsky S, Messerli FH, Bangalore S, Champion A, Cooper-Dehoff RM, Zhou Q, Pepine CJ. Obesity paradox in patients with hypertension and coronary artery disease. Am J Med. 2007 Oct;120(10):863-70.
3. Imayama I, Alfano CM, Kong A, Foster-Schubert KE, Bain CE, Xiao L, Duggan C, Wang CY, Campbell KL, Blackburn GL, McTiernan A. Dietary weight loss and exercise interventions effects on quality of life in overweight/obese postmenopausal women: a randomized controlled trial. Int J Behav Nutr Phys Act. 2011 Oct 25;8:118.
4. Bangalore S, Sawhney S, Messerli FH. Relation of beta-blocker-induced heart rate lowering and cardioprotection in hypertension. J Am Coll Cardiol. 2008 Oct 28;52(18):1482-9.
5. Hemingway, Ernest. Across the River and Into the Trees. Charles Scribner's Sons. September 1950.
Lauer MS. Lemons for Obesity. Ann Intern Med. ;157:139–140. doi: 10.7326/0003-4819-157-2-201207170-00438
Download citation file:
Published: Ann Intern Med. 2012;157(2):139-140.
Results provided by:
Copyright © 2018 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use