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Family Medicine - Adult General Internal Medicine
Network meta-analysis of insomnia medications in adults (July 2022)
A large number of medications spanning multiple classes are available for treatment of insomnia, but few long-term or comparative trials have been performed. This was illustrated by a network meta-analysis, which identified 154 placebo-controlled randomized trials of 30 different medications for insomnia in nearly 45,000 participants, of which only five trials were longer than 4 weeks, and nearly all comparisons relied on indirect evidence and a small subset of the total number of trials.2 While the study concluded that eszopiclone, a benzodiazepine receptor agonist (BZRA), and lemborexant, a dual orexin receptor antagonist (DORA), appeared to be the most favorable medications for overall efficacy and tolerability, confidence was limited by known adverse effects of BZRAs and inconclusive long-term safety data for DORAs. In addition, patients with insomnia seen in clinical practice represent a broader population than those enrolled in clinical trials, and treatment decisions must weigh individual risks and benefits of medications along with all other available therapies.
Allergy and Immunology - Vaccines and Vaccine Hypersensitivity
No evidence that PEG is the cause of allergic reactions to mRNA COVID-19 vaccines (July 2022)
When initial reports of allergic reactions to SARS-CoV-2 messenger ribonucleic acid (mRNA) vaccines appeared, the excipient polyethylene glycol (PEG) 2000 was implicated as the possible causative agent because higher molecular weight PEGs and related polysorbates have rarely caused anaphylaxis. However, several case series have documented uneventful mRNA vaccinations in a total of over 300 patients who had known or probable PEG allergy and past reactions to PEG-containing medications.3,4 These findings suggest that PEG 2000 is not the likely cause of apparent anaphylaxis after vaccination with mRNA vaccines. Patients with past allergic reactions to PEG or polysorbate in other medications can safely receive mRNA COVID-19 vaccines without prior PEG skin testing or other special precautions.
Family Medicine - Adult General Internal Medicine
Vitamin D supplementation in community-dwelling individuals did not show a fracture benefit (August 2022)
In the VITAL trial, in which 25,871 community-dwelling men and women (mean age 67 years) were randomly assigned to vitamin D (2000 units daily) or placebo, the rate of total fractures (5.9 versus 6 percent), nonvertebral fractures (5.6 versus 5.7 percent), and hip fractures (0.44 versus 0.43 percent) was similar in the two groups.1 The participants were not selected on the basis of vitamin D deficiency, low bone mass, or osteoporosis. The mean 25-hydroxyvitamin D level (in a subset of participants) was 30 ng/mL (75 nmol/L). Approximately 10 percent of the total group had a history of a fragility fracture, and approximately 5 percent were taking osteoporosis medications. Community-dwelling adults who are getting adequate calcium and vitamin D from dietary intake (and sun exposure) do not need to take additional supplements. Vitamin D supplementation is typically suggested as part of the treatment of osteoporosis, particularly for patients who are receiving osteoporosis medications.
1. LeBoff MS, Chou SH, Ratliff KA, et al Supplemental vitamin D and incident fractures in midlife and older adults. N Engl J Med. 2022;387(4):299. [Context Link]
2. De Crescenzo F, D'Alo GL, Ostinelli EG, et al Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis. Lancet. 2022;400(10347):170. [Context Link]
3. Picard M, Drolet JP, Masse MS, et al Safety of COVID-19 vaccination in patients with polyethylene glycol allergy: A case series. J Allergy Clin Immunol Pract. 2022;10(2):620. Epub 2021 Dec 20. [Context Link]
4. Otani IM, Tsao LR, Tang M. Coronavirus disease 2019 vaccine administration in patients with reported reactions to polyethylene glycol- and polysorbate-containing therapeutics. Ann Allergy Asthma Immunol. 2022;129(1):88. Epub 2022 Mar 12. [Context Link]
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