therapy

The first question a patient often asks their FP after receiving a diagnosis of breast cancer (BC) is “What will my treatment be?” This article will help FPs answer this complex question by reviewing multimodal therapy for BC, which is contingent on molecular subtype and stage.

Author/s:

Wilkinson, A. N.

Diagnosis and management of patients with polyneuropathy

Aubrey Delammermore — Wed, 15 Feb 2023 06:00:00 +0000

Date Added:

February 15, 2023

Journal/Publication:

CMAJ

Publisher:

CMA Impact Inc

Publication Date:

February 13, 2023

Issue:

Volume:

195

Pages:

E227-E233

URL:

Diagnosis and management of patients with polyneuropathy

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.220936

Keywords

PMID (1):

36781195

MeSH

Polyneuropathies* / diagnosis

Polyneuropathies* / therapy

Humans

diabetic neuropathies

Neurologic Examination

A general review of polyneuropathy syndromes noting red flags and a diagnostic algorithm. James W. Mold, MD, MPH

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Polyneuropathy is a common neurologic condition with an overall prevalence in the general population of about 1%–3%, increasing to roughly 7% among people older than 65 years. Polyneuropathy has many causes, and can present in many different ways; thus, it requires a logical clinical approach for evaluation, diagnosis and management. We review the approach to evaluating a patient with polyneuropathy by highlighting important aspects of the history and neurologic examination. We focus on the role of diagnostic investigations for distal symmetric polyneuropathy (DSP), the most common subtype, and an approach to the symptomatic treatment of painful diabetic polyneuropathy (PDN). We draw on practice based guidelines, meta-analyses and systematic reviews, where
possible, as they represent the highest levels of evidence (Box 1).

Author/s:

Mirian, A., Aljohani, Z., Grushka, D., Florendo-Cumbermack, A.

Therapy for Mild to Moderate Asthma

Aubrey Delammermore — Wed, 27 Jul 2022 05:00:00 +0000

Date Added:

July 27, 2022

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

July 21, 2022

Pages:

URL:

Therapy for Mild to Moderate Asthma

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2022.12258

Keywords

asthma

Mild to Moderate Asthma

therapy

recommendations

Asthma Therapy

PMID (1):

35862052

MeSH

asthma

adrenal cortex hormones

nebulizers and vaporizers

formoterol fumarate

-(2-(4-azidobenzamidino)ethyl)-5-hydroxyindole

Updated guidelines for management of mild to moderate asthma. James W. Mold, MD,MPH

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GUIDELINE TITLE Global Strategy for Asthma Management
and Prevention (GINA Strategy Report)
RELEASE DATE April 26, 2021
PRIOR VERSION April 3, 2020
DEVELOPER AND FUNDING SOURCE The Global Initiative for
Asthma (GINA)
TARGET POPULATION Patients aged 12 y with asthma
MAJOR RECOMMENDATIONS
• Short-acting β-agonist (SABA) monotherapy is no longer
recommended (level of evidence: A).
• There is no distinction between mild-intermittent
and mild-persistent asthma; inhaled corticosteroid
(ICS)–containing therapies are recommended for
both. ICS-formoterol is recommended as the preferred
reliever inhaler (level of evidence: A).
• For treatment of moderate asthma, GINA recommends
ICS-formoterol maintenance and reliever therapy in
the preferred track (level of evidence: A).

Author/s:

Gray, S. E., Cife, A. S., Press, V. G.

Evaluation of Budesonide-Formoterol for Maintenance and Reliever Therapy Among Patients With Poorly Controlled Asthma A Systematic Review and Meta-analysis

Saige Blanchard — Thu, 10 Mar 2022 06:00:00 +0000

Date Added:

March 10, 2022

Journal/Publication:

JAMA Network Open

Publisher:

JAMA Network Open

Publication Date:

December 21, 2021

Issue:

Volume:

URL:

Evaluation of Budesonide-Formoterol for Maintenance and Reliever Therapy Among Patients With Poorly Controlled Asthma A Systematic Review and Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2022.0615

Keywords

Budesonide-Formoterol

therapy

asthma

Inhaler

PMID (1):

35230437

MeSH

For adults with moderate to severe asthma, use of a budesonide-formoterol inhaler for both maintenance and rescue (SMART protocol) appears to be more effective than usual step care with two or three different inhalers. (Once again, simpler is often better.) James W. Mold, MD, MPH

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Importance: The Global Initiative for Asthma (GINA) recommends 2 alternative treatments for patients receiving treatment at steps 3 to 5: single inhaler combination inhaled corticosteroid-formoterol as both maintenance and reliever (SMART) or inhaled corticosteroid-long-acting β2-agonist as maintenance plus short-acting β2-agonist as reliever.

Objective: To assess whether switching to SMART is associated with longer time to first severe asthma exacerbation compared with a step up or continuation of GINA treatment step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever among patients with poorly controlled asthma.

Data sources: For this systematic review and meta-analysis, the literature, internal study databases at AstraZeneca and the Medical Research Institute of New Zealand, and references from a previous systematic review and meta-analysis on SMART were searched to identify randomized clinical trials published from January 1990 to February 2018, that compared budesonide-formoterol by SMART with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever.

Study selection: Trials of at least 24 weeks' duration were included if they reported baseline data on GINA treatment step, asthma control status, and efficacy measures of severe exacerbations. Included patients were adults and adolescents with asthma and baseline Asthma Control Questionnaire 5-item version scores of 1.5 or higher.

Data extraction and synthesis: Patient-level data were identified by independent extraction, and analyses were performed using a fixed-effect model. Data analysis was performed from August 2018 to November 2021.

Main outcomes and measures: The primary outcome was time to first severe asthma exacerbation associated with each treatment, analyzed by Cox proportional hazards regression.

Results: Overall, 4863 patients were included (3034 [62.4%] female; mean [SD] age, 39.8 [16.3] years). Switching patients with uncontrolled asthma at GINA step 3 (n = 1950) to SMART at either step 3 or 4 was associated with a prolonged time to first severe asthma exacerbation, with a 29% reduced risk compared with stepping up to step 4 inhaled corticosteroid-long-acting β2-agonist maintenance plus short-acting β2-agonist reliever (hazard ratio, 0.71; 95% CI, 0.52-0.97). For patients with uncontrolled asthma at step 3 and step 4 (n = 2913), switching to SMART was associated with a prolonged time to first severe asthma exacerbation and a 30% reduced risk compared with remaining at the same treatment step (hazard ratio, 0.70; 95% CI, 0.58-0.85).

Conclusions and relevance: In this systematic review and meta-analysis, for patients with poorly controlled asthma, SMART was associated with longer time to first severe asthma exacerbation compared with a step up or continuation of GINA step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever. These findings suggest that if an adult or adolescent receiving treatment at GINA step 3 or 4 has poorly controlled asthma, it is preferable to switch to the SMART regimen rather than to step up or continue the GINA treatment step with maintenance inhaled corticosteroid-long-acting β2-agonist plus short-acting β2-agonist reliever therapy.

Author/s:

Beasley, R., Harrison, T., Peterson, S., Gustafson, P., Hamblin, A., Bengtsson, T., Fageras, M.

Pharmacologic and Nonpharmacologic Therapies in Adult Patients With Exacerbation of COPD: A Systematic Review

John Bayhi — Fri, 18 Oct 2019 13:01:46 +0000

Date Added:

October 18, 2019

Journal/Publication:

AHRQ Website

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

October 11, 2019

URL:

Pharmacologic and Nonpharmacologic Therapies in Adult Patients With Exacerbation of COPD

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.23970/AHRQEPCCER221

Keywords

copd

chronic obstructive pulmonary disease

therapy

randomized control trial

systematic review

Key points are on page ii. Antibiotics and corticosteroids and some non-pharmacologic strategies are effective. We still don’t know the best corticosteroid dose or route. James W. Mold, MD, MPH

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Objectives. To synthesize existing knowledge about the effectiveness and harms of pharmacologic and nonpharmacologic treatments for exacerbations of chronic obstructive pulmonary disease (ECOPD).

Data sources. Embase®, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, MEDLINE® Daily, MEDLINE, Cochrane Central Registrar of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus from database inception to January 2, 2019.

Review methods. We included randomized controlled trials (RCTs) that evaluated pharmacologic intervention or nonpharmacologic interventions for ECOPD. The strength of evidence (SOE) was graded for critical final health outcomes.

Results. We included 98 RCTs (13,401 patients, mean treatment duration 9.9 days, mean followup 3.7 months). Final health outcomes, including mortality, resolution of exacerbation, hospital readmissions, repeat exacerbations, and need for intubation, were infrequently evaluated and often showed no statistically significant differences between groups. Antibiotic therapy increases the clinical cure rate and reduces the clinical failure rate regardless of the severity of ECOPD (moderate SOE). There is insufficient evidence to support a particular antibiotic regimen. Oral and intravenous corticosteroids improve dyspnea and reduce the clinical failure rate (low SOE). Despite the ubiquitous use of inhaled bronchodilators in ECOPD, we found only a small number of trials that assessed lung function tests, and not final health outcomes. The evidence is insufficient to support the effect of aminophyllines, magnesium sulfate, mucolytics, inhaled corticosteroids, inhaled antibiotics, 5-lipoxygenase inhibitor, and statins on final health outcomes. Titrated oxygen reduces mortality compared with high flow oxygen (low SOE). Low SOE suggested benefit from some nonpharmacologic interventions such as chest physiotherapy using vibration/percussion/massage or breathing technique (on dyspnea), resistance training (on dyspnea and quality of life), early pulmonary rehabilitation commenced before hospital discharge during the initial most acute phase of exacerbation rather than the convalescence period (on dyspnea) and whole body vibration training (on quality of life). Vitamin D supplementation may improve quality of life (low SOE).

Conclusions. Although chronic obstructive pulmonary disease is a common condition, the evidence base for most interventions in ECOPD remains limited. Systemic antibiotics and corticosteroids are associated with improved outcomes in mild and moderate to severe ECOPD. Titrated oxygen reduces mortality. Future research is required to assess the effectiveness of several emerging nonpharmacologic and dietary treatments.

Author/s:

Dobler, CC, Morrow, AS, Farah, MH, Beuschel, B, Majzoub, AM, Wilson, ME, Hasan, B, Seisa, MO, Daraz, L, Prokop, LJ, Murad, MH, Wang, Z

Effectiveness of brief alcohol interventions in primary care populations

Tracy Ashby — Mon, 12 Nov 2018 06:00:00 +0000

Date Added:

November 12, 2018

Journal/Publication:

Cochrane Database of Systematic Reviews

Publisher:

John Wiley & Sons, Inc.

Publication Date:

February 24, 2018

Issue:

URL:

Effectiveness of brief alcohol interventions in primary care populations

Type:

Meta-analyses, Reviews, and Guidelines, Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1002/14651858

Keywords

MeSH

motivational interviewing

cognitive therapy

Screening and brief interventions for unhealthy levels of alcohol use in primary care settings are effective for reducing alcohol intake. A number of screening instruments are available. Evidence-based brief interventions have generally included: feedback on the screening outcome plus structured advice about potential risks of heavy drinking and ways to reduce consumption. Effective feedback and advice has taken several forms including: FRAMES, motivational interviewing, Motivational Enhancement Therapy (MET), Brief Negotiated Interview (BNI), and/or Cognitive Behavioral Therapy (CBT). Some have been backed up by diaries or exercises for the patient to complete at home, and follow-up telephone calls.

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Background

Excessive drinking is a significant cause of mortality, morbidity and social problems in many countries. Brief interventions aim to reduce alcohol consumption and related harm in hazardous and harmful drinkers who are not actively seeking help for alcohol problems. Interventions usually take the form of a conversation with a primary care provider and may include feedback on the person’s alcohol use, information about potential harms and benefits of reducing intake, and advice on how to reduce consumption. Discussion informs the development of a personal plan to help reduce consumption. Brief interventions can also include behaviour change or motivationally-focused counselling.

This is an update of a Cochrane Review published in 2007.

Author/s:

Kaner, EFS, Beyer, FR, Muirhead, C, Campbell, F, Pienaar, ED, Bertholet, N, Daeppen, JB, Saunders, JB, Burnand, B

Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder: A Systematic Review Update

Jeffrey Wilson — Thu, 23 Aug 2018 16:35:02 +0000

Date Added:

August 23, 2018

Journal/Publication:

Comparative Effectiveness Review

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

May 17, 2018

Issue:

URL:

Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder: A Systematic Review Update

Type:

Meta-analyses, Reviews, and Guidelines, Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.23970/AHRQEPCCER207

Keywords

PTSD

therapy

MeSH

stress disorders, post-traumatic

This AHRQ evidence review summarizes the effectiveness of various non-pharmacologic and pharmacologic treatments for PTSD. The tabular results are on pages E3 – E6.

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Objective. To assess efficacy, comparative effectiveness, and harms of psychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD) and to update the original 2013 review.

Data sources. MEDLINE®, CINAHL®, Cochrane Library, Cochrane Clinical Trials Registry, PILOTS (Published International Literature on Traumatic Stress), PsycINFO®, and reference lists of published literature (May 2012–September 2017).

Review methods. Two investigators independently selected, extracted data from, and rated risk of bias of relevant studies. We conducted meta-analyses or network meta-analyses using random-effects models when we had evidence from three or more studies with low heterogeneity. We graded strength of evidence (SOE) following established Agency for Healthcare Research and Quality guidance.

Results. We included 193 randomized controlled trials (207 articles) for this review.

Several psychological treatments were associated with the reduction of PTSD symptoms and loss of PTSD diagnosis compared with inactive comparators; high SOE supports efficacy of cognitive behavioral therapy (CBT)-exposure and CBT-mixed treatments, and moderate SOE supports efficacy of cognitive processing therapy (CPT), cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy (NET). When directly comparing two treatments of interest, moderate SOE favors CBT-exposure over relaxation therapy.

Several pharmacological treatments reduced PTSD symptoms; moderate SOE supports the efficacy of fluoxetine, paroxetine, and venlafaxine compared with placebo. Our network meta-analysis (33 trials; N=4,817) of Clinician-Administered PTSD Scale (CAPS)-measured PTSD symptoms showed no differences in effectiveness between medications with at least moderate SOE of efficacy (fluoxetine, paroxetine, and venlafaxine) (low SOE for no difference).

Studies provided insufficient strength of evidence for serious adverse events associated with any treatments of interest. The majority of psychological studies reported no information about adverse events. Among pharmacological treatments with evidence of efficacy (moderate SOE), we found increased risk of nausea with venlafaxine compared with placebo (moderate SOE).

Our review found insufficient strength of evidence for the comparative effectiveness of any psychological versus pharmacological treatment and for differences in the efficacy or comparative effectiveness of treatments by patient characteristics (e.g., co-occurring conditions) or type, number, severity, or chronicity of trauma exposure(s). We did not find evidence for many of our outcomes of interest or interventions of interest, including the newer treatments added since our prior review.

Conclusions. Several psychological and pharmacological treatments have moderate to high SOE of efficacy for treating adults with PTSD. Future research is needed on the comparative effectiveness of treatments (including different comparisons of psychological and pharmacological treatments), differences in treatment benefits by trauma type or other patient characteristics, and adverse events associated with treatments.

Author/s:

Forman-Hoffman, Valerie, Middleton, Jennifer Cook, Feltner, Cynthia, Gaynes, Bradley N., Weber, Rachel Palmieri, Bann, Carla, Viswanathan, Meera, Lohr, Kathleen N., Baker, Claire, Green, Joshua