Annals of Long Term Care

Thiazolidinediones and Cardiovascular Outcomes in Older Patients With Diabetes
Cardiovascular disease is an important cause of morbidity and mortality among persons with type 2 diabetes mellitus. The thiazolidinediones (TZDs) rosiglitazone and pioglitazone are oral hypoglycemic agents that have been shown to improve glycemic control and may act to slow the progression of beta cell failure. While improved glycemic control has been linked to better clinical outcomes in diabetes and TZDs have been suggested as having potential cardiovascular benefits, recent concerns have arisen regarding adverse cardiac effects of these drugs. TZDs, used to treat type 2 diabetes, are associated with an excess risk of congestive heart failure, and possibly acute myocardial infarction. However, the association between TZD use and cardiovascular events has not been adequately evaluated on a population level.

The researchers’ objective in this study was to explore the association between TZD therapy and congestive heart failure, acute myocardial infarction, and mortality as compared to treatment with other oral hypoglycemic agents. A nested case-control analysis of a retrospective cohort study was conducted using healthcare databases in Ontario, and included diabetes patients age 66 years or older treated with at least one oral hypoglycemic agent between 2002 and 2005 (N=159,026) and followed them up until March 31, 2006. The primary outcome consisted of an emergency department visit or hospitalization for congestive heart failure; secondary outcomes were an emergency department visit or hospitalization for acute myocardial infarction and all-cause mortality. The risks of these events were compared between persons treated with TZDs (rosiglitazone and pioglitazone) and other oral hypoglycemic agent combinations, after matching and adjusting for prognostic factors. During a median follow-up of 3.8 years, 12,491 patients (7.9%) had a hospital visit for congestive heart failure, 12,578 (7.9%) had a visit for acute myocardial infarction, and 30,265 (19%) died. Current treatment with TZD monotherapy was associated with a significantly increased risk of congestive heart failure (78 cases; adjusted rate ratio [RR], 1.60; 95% confidence interval [CI], 1.21-2.10; P<.001), acute myocardial infarction (65 cases; RR, 1.40; 95% CI, 1.05-1.86; P=.02), and death (102 cases; RR, 1.29; 95% CI, 1.02-1.62; P=.03) compared with other oral hypoglycemic agent combination therapies (3478 congestive heart failure cases, 3695 acute myocardial infarction cases, and 5529 deaths). The increased risk of congestive heart failure, acute myocardial infarction, and mortality associated with TZD use appeared limited to rosiglitazone.

The authors concluded that in this population-based study of older patients with diabetes, TZD treatment, primarily with rosiglitazone, was associated with an increased risk of congestive heart failure, acute myocardial infarction, and mortality when compared with other combination oral hypoglycemic agent treatments.

JAMA 2007;298(22):2634-2643
Lorraine L. Lipscombe, MD, MSc, Tara Gomes, MHSc, Linda E. Lévesque, BScPhm, MSc, Janet E. Hux, MD, MSc, David N. Juurlink, BPhm, MD, PhD, David A. Alter, MD, PhD

High-Trauma Fractures and Low Bone Mineral Density in Older Women and Men
Approximately 1.5 million osteoporotic fractures occur each year in the United States.! As the population ages, the number of fractures is projected to increase almost 4-fold by 2050 if effective prevention strategies are not implemented. The criteria used to define osteoporotic fractures warrant further investigation. By the current definition, fractures are recognized as osteoporotic if they are associated with low bone mineral density (BMD) and if they increase the risk of subsequent fracture. It remains unclear whether degree of trauma should be included in the definition of osteoporotic fractures.