Selective Beta-blockers for COPD
The (2002, Issue 2) issue of the Cochrane Library contains several reviews that are relevant to Primary Care. I will start with one that I have worked on relating to selective Beta-blockers and Chronic Obstructive Pulmonary Disease (COPD). In general Beta-blockers have been shown to be useful in secondary prevention for patients with ischaemic heart disease, but problems arise because many of these patients have smoked and also have COPD so we may be reluctant to consider a Beta-blocker in case this makes the chest problems worse.
The new review suggests that Cardioselective beta-blockers do not cause important deterioration in COPD and should not be withheld in patients with COPD (1). This is how the abstract puts it:
Eleven studies of single-dose treatment and 8 of treatment for longer durations, ranging from 2 days to 12 weeks, met selection criteria. Cardioselective beta-blockers, given as a single dose or for longer duration, produced no significant change in FEV1 or respiratory symptoms compared to placebo, and did not significantly affect the FEV1 treatment response to beta2-agonists. A subgroup analysis revealed no significant change in results for those participants with severe chronic airways obstruction or for those with a reversible obstructive component.
Cardioselective beta-blockers, given to patients with COPD do not produce adverse respiratory effects. Given their demonstrated benefit in conditions such as heart failure, coronary artery disease and hypertension, cardioselective beta-blockers should not be withheld from patients with COPD.
Treatments for Tennis elbow
A review on tennis elbow (2)has shown topical NSAID treatment to be effective in the short-term relief of pain (although this comes from only 150 patients randomised) and even smaller numbers of patients from 2 trials suggested that patients were more likely to show subjective improvement with symptoms (in the short term) following a steroid injection than oral NSAID. More work is needed to see how topical NSAID treatment compares to oral NSAID and to study the outcomes for longer than 4 weeks.
A note of caution on the comparison between steroid injection and oral NSAID; as the outcome was subjective I would be concerned about bias in trials with no dummy injection. There was only one study (Saartok 1986) that did use a dummy injection and this did not show a significant difference from NSAID, whereas the other study (Hay 1999) with no dummy injection did show a significant benefit. A larger double blind double dummy study with a head to head comparison is therefore needed to confirm whether there is a real difference between these two approaches.
Other new reviews
Other new reviews have found no important differences between carbamezepine and phenytoin as monotherapy for epilepsy, no good evidence to recommend dehumidifiers in asthma, and interestingly only one randomised controlled trial on 22 patients was found comparing surgical with non-surgical treatment of carpal tunnel syndrome. Clearly more research needed here!
1. Salpeter S, Ormiston T, Salpeter E, Poole P, Cates C. Cardioselective beta-blockers for chronic obstructive pulmonary disease (Cochrane Review). In: Cochrane Library. 2 ed: Update Software (Oxford); 2002.
2. Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, et al. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults (Cochrane Review). In: The Cochrane Library: Oxford: Update Software; 2002(Issue 2).