It's been a while since I looked closely at 5 alpha reductase inhibitors. In March 2011, I discussed the potential side effects from taking a 5ARI. In July 2011, I reviewed two studies aimed at using a 5ARI as chemoprophylaxis against prostate cancer. Unfortunately, the results didn't turn out as hoped and the Food & Drug Administration refused to give either finasteride or dutasteride approval for marketing as preventing prostate cancer.
Well, in a case-control study published 10 days ago in the British Medical Journal, the authors concluded that use of 5ARIs to treat lower urinary tract symptoms also lowered Gleason score 2-7 prostate cancer. This was an expected outcome. What was unexpected was that 5ARI use did not increase risk of Gleason 8-10 prostate cancer in the ensuing 4yrs. Recall that while both the Prostate Cancer Prevention Trial (PCPT) and the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial demonstrated that regular use of 5ARIs can lower prostate cancer risk by up to 1 in 4, they also increased high grade prostate cancer risk.
So how does a guy decide? Well, for now, use the 5ARI for its intended purpose, assuming you still need it. That means take it for your receding hair line or because you have symptoms of an enlarged prostate. But don't take it in an attempt to prevent prostate cancer. At least not until we have better research to support such an indication.
Remember FAST? That's the acronym for stroke symptoms: Face, Arm, Speech & Time. In other words, if your face doesn't look right (it's droopy), your arms (or legs) are weak/clumsy, and/or your speech is slurred, you don't have much time to call 911 & get to a stroke center for emergent imaging & potential treatment, eg clot busting drugs. Bit of advice: don't drive yourself to the hospital, you might get worse & lose control of your vehicle. So get someone else to drive you there.
So what's a TIA? Transient ischemic attack. It's a small or minor or mini-stroke in which you regain your function in less than a few hours and return to baseline w/o any function loss or impairment. The problem with the TIA is that it's a warning shot across the bow. It's the canary in the mine. In a not so small percentage of patients who've suffered a TIA, they go on to sustain a massive stroke in the next few days to weeks, up to a third in a year, w/complete permanent loss of function.
So how do you prevent this from happening? Well, if the symptoms were witnessed & definitely stroke-like, and occurred during the day and you can get in contact with your family physician, sometimes s/he can push through a rapid evaluation (brain scan, carotid ultrasound, electrocardiogram, echocardiogram) & aggressively treat your risk factors, eg high blood pressure, high cholesterol & high sugars. However, these tests may take several days if not weeks to obtain as an outpatient if your insurance is particularly meddlesome. That's why the evaluation of a suspected TIA is often best expedited in the ER where everything can be done before you're sent home.
But then what? Your evaluation is negative but you still had that event. What's your next step? In the past, we've discussed the option of aspirin vs warfarin. However, in a randomized placebo controlled study published early online in the New England Journal of Medicine, the authors concluded that aspirin + clopidogrel prevented more ischemic strokes than aspirin alone. Better yet, there was no increase risk of hemorrhagic strokes. To arrive at their conclusion, the authors randomized 5,170 participants avg 62yo to either aspirin alone or aspirin + clopidogrel. Within the 1st 90 days of treatment, offering clopidogrel to 29 participants would prevent one stroke.
God forbid you're (un)lucky enough to have a TIA. Ask your doc about using dual anti-platelet agents to prevent a stroke.
The latest supplement being lobbed back & forth these days is vitamin D. At the very least, we have plenty of cause & effects studies demonstrating that vitamin D is necessary for bone health. Without enough vitamin D, we end up with rickets. But what about health matters unrelated to bone? Heart disease? Diabetes? Cancer?
In a fashion not unlike that of the National Security Administration, except with permission & proper supervision, the authors gathered data from 10,170 men & women avg 47yo participating in the National Health & Nutrition Examination Study and correlated this with the National Death Index for an average of just under 4yrs. They noted that low levels of 25OH vitamin D, up to what's currently considered insufficiency at 21ng/mL, were associated with increase risk of death from both all-causes & heart disease. This is consistent w/recent reviews concluding that "normal" values in 30-100ng/mL range do not improve upon outcomes.
Yet despite the fact that this study supports the trend of studies linking vitamin D to our health, there's still no conclusive proof of cause & effect. So what are we to do in the meantime? Well, the good news is that unless you exceed 100ng/mL, it's unlikely that you'll suffer from hypercalcemia & other maladies. In other words, vitamin D supplementation appears to be safe, as far as we currently know. Which then makes it easier to consider supplementation if we don't have time to wait around for a cause & effect trial. Of course, this is something that should be discussed w/your family physician. And don't forget to think like Goldilocks. You want your 25OH vitamin D level just right, not too high & clearly, not too low.
Really? Are we sure? Couldn't this just be a fluke outcome? After all, the trend in studies is that of benefit from lifestyle modifications. How could this one come out against diet & exercise? Well, the authors followed for almost 10 years 5,145 (wo)men avg age 59 w/avg body mass index 36 (obese by definition) who'd had diabetes for an average of 5yrs already. These participants had been randomized to either intensive lifestyle intervention focusing on weight loss via diet & exercise vs the control group who were given standard diabetic education.
At the end of the 1st year, those randomized to intervention lost 8.6% body weight compared to 0.7% in the control group. By the end of the study, the difference had narrowed dramatically to just 6% in the intervention group vs 3.5% in the control group. This minor difference in weight loss might account for the lack of difference in heart disease.
However, those in the intervention group who lost weight & kept it off did demonstrate greater decrease in A1c as well as better fitness & cardiovascular risk factors (aside from LDL). And while it's not clear whether the egg came before the hen or vice versa, those in the intensive intervention group had a lower rate of cardioprotective medication use. Could that lower rate of use led to the lack of difference in heart disease outcomes? Or perhaps, the lower need for medications was a result of benefit gained from intensive interventional change in lifestyle. If you're a cynic and look for trends, check out the editorial for plausible reasons to explain this fluke.
As for me, I look at all the benefits gained from lifestyle modifications and the lack of harm, too. I believe this study is a fluke in that it didn't show benefit in heart disease. But just you wait & see. Given a large enough study for a long enough period of time w/great enough inter-group differences . . .
It's been said that hormonal young men w/high levels of testosterone are constantly thinking about sex. Certainly, as we age, our libido decreases. Whether this is a result of a natural decline in testosterone or of cognitive maturity is open to debate. It's also been reported that hypogonadal men are more depressed & perhaps not as sharp cognitively speaking. Some studies even show a benefit to testosterone replacement in such men w/low T.
But what about women? Well, my disclaimer is that the following info has not been published in a peer reviewed journal but rather was presented at last week's meeting of endocrinologists. The authors randomized 92 healthy postmenopausal women avg 60yo who had both normal cognitive function and as well, had not taken any systemic hormone therapy, to 0.22g of testosterone as a transdermal gel or to a placebo for 26wks.
The authors noted that while these postmenopausal women were cognitively intact, those randomized to T still scored statistically significantly better than those who received placebo. The improvement was coincident to an increase in testosterone level from low normal to mid-normal range. Luckily, there were no negative outcomes in this small short study. If you can't wait, ask your doc about this way off-label use of T. But just to be on the safe side, wait if you can afford to do so.