Arefa MD’s Morning Report: Bisphosphonates & Mortality; Type 1 Diabetes in Adults, Treating HCV

Arefa Cassoobhoy, MD, MPH


September 30, 2016

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Hello. I'm Dr Arefa Cassoobhoy, a practicing internist and a medical editor for Medscape and WebMD. Welcome to our weekly brief on recent medical news and findings.

Could This Be Type 1?

Our first report provides surprising evidence that about half of new diagnoses of type 1 diabetes occur in adults over the age of 30 years.

There's been a long-held perception that type 1 diabetes is primarily a juvenile condition. The new study debunks that concept, finding that autoimmune diabetes develops at any age. The researchers looked at genetic data from 120,000 white adults in the United Kingdom.

Although the vast majority of new-onset diabetes cases are type 2, about 5% of adults newly diagnosed with diabetes have type 1 diabetes. These adults are generally younger and are slightly slimmer than those with type-2. They are also far more likely to be on insulin within a year of diagnosis.

As physicians, this news should make us more aware. If our patients aren't responding to the usual type 2 treatments, we need to have a higher index of suspicion that they may have type 1 diabetes.

Before You Treat Hepatitis C...

If you have a patient with hepatitis C virus (HCV), it is important to screen them for hepatitis B virus (HBV) before you start direct-acting antiviral treatment. Guidelines were recently updated after case reports described reactivation of HBV in patients with both HBV and HCV who were only treated for HCV. The thought is that the reactivation may have to do with an increase in hepatitis B viral replication after the HCV is cleared. It does not seem to be due to toxicity from any specific drug.

To ensure successful therapy for patients with HCV, it is important that the HBV treatment start before or at the same time as treatment for HCV. If your patient does not meet criteria for HBV treatment because their viral load is low or undetectable, they will still need to be followed closely for reactivation, which can be very serious.

Bisphosphonates Reduce All-Cause Mortality

And finally, taking bisphosphonates reduces all-cause mortality rates in both women and men 50 years or older. In those with a history of a fracture, mortality rates are decreased by 35% or more. The data come from the prospective Canadian Multicentre Osteoporosis study which included approximately 5300 participants.

The vast majority of the benefit is attributed to the bisphosphonate alendronate. Risedronate had a possible benefit, though that is a newer drug with fewer patients taking it, so we need more data to evaluate it. Etidronate had no significant survival benefits at all.

This information is consistent with other trials that have found a decrease in mortality risk with bisphosphonates. It is still not understood just why alendronate, in particular, increased survival, but it is interesting that the survival advantage was not related to a decline in subsequent fractures.

Overall, given the magnitude of the effect of the bisphosphonates, the findings underscore the need to treat osteoporosis and begin therapy immediately after a patient has a fragility fracture.

For Medscape and WebMD, I'm Dr Arefa Cassoobhoy.

Follow Dr Cassoobhoy at @ArefaMD.


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