Sunshine: Clinical Friend or Foe?

But soft! What light through yonder window breaks? It is the east, and Juliet is the sun! Arise, fair sun, and kill the envious moon …

Shakespeare, W: Romeo and Juliet, Act II, Scene II.

When you live in Arizona, the sun is always with you. Living here makes it easy to understand that the sun has been a central factor in human existence, iconography, and a variety of religions in ancient Egypt, Indo-Europe, and Meso-America since the beginning of recorded or archaeologically defined history. (1,2)

The first scientific writings concerning the benefit of sun therapy emanated from the investigations of Niels Ryberg Finsen, who won the Nobel Prize for his work with heliotherapy (Helios in ancient Greek = sun).(3) Finsen observed the effect of sunlight on his own fragile health. He supplemented these personal observations with experiments on animals and eventually began a series of clinical trials using natural and artificial sunlight therapy for 2 skin conditions: smallpox and tuberculosis of the skin. The dermatologic lesions of both conditions responded to natural and artificial sunlight exposure in these experiments, eventually leading to the Nobel Prize in 1903.(4)

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-- Joseph S. Alpert, MD, Editor-in-Chief

This article originally appeared in the April 2010 issue of The American Journal of Medicine.

Long-acting Beta-Agonists with and without Inhaled Corticosteroids and Catastrophic Asthma Events

There is a 3-fold increase in asthma-related intubations and deaths in those taking long-acting beta-agonists with concomitant corticosteroids compared to corticosteroids alone, according to this meta-analysis.

Abstract
Background
It is unclear whether long-acting β-agonists with concomitant inhaled corticosteroids increase asthma-related intubations and deaths. We pooled data on long-acting β-agonists with variable and concomitant inhaled corticosteroids to evaluate the risk for catastrophic asthma events.

Methods
We conducted searches of electronic databases, the US Food and Drug Administration website, clinical-trials registries, and selected references through December 2008. We analyzed randomized controlled trials in patients with asthma, which lasted at least 3 months, evaluated long-acting β-agonists compared with placebo or long-acting β-agonists with inhaled corticosteroids compared with corticosteroids alone, and included at least 1 catastrophic event, defined as asthma-related intubation or death.

Results
In pooled trial data that included 36,588 participants, long-acting β-agonists increased catastrophic events 2-fold (Peto odds ratio [OR] 2.10; 95% confidence interval [CI], 1.37-3.22). Statistically significant increases were seen for long-acting β-agonists with variable corticosteroids compared with placebo (OR 1.83; 95% CI, 1.14-2.95) and for concomitant treatment with corticosteroids compared with corticosteroids alone (OR 3.65; 95% CI, 1.39-9.55). Similar increases in risk were seen for variable and concomitant corticosteroid use, salmeterol and formoterol, and children and adults. When the analysis was restricted to trials with controlled corticosteroid use, given as part of the study intervention, concomitant treatment still increased catastrophic events compared with corticosteroids alone (OR 8.19; 95% CI, 1.10-61.18).

Conclusion
Long-acting β-agonists increase the risk for asthma-related intubations and deaths, even when used in a controlled fashion with concomitant inhaled corticosteroids.

To read this article in its entirety, please visit our website.

-- Shelley R. Salpeter, MD, FACP, Andrew J. Wall, MD, Nicholas S. Buckley

This article originally appeared in the April 2010 issue of The American Journal of Medicine.