treatment

Importance: Type 2 diabetes involves progressive loss of insulin secretion from pancreatic β cells in the setting of insulin resistance and manifests clinically as hyperglycemia. Type 2 diabetes accounts for 90% to 95% of all cases of diabetes globally, with estimates ranging from 589 million to 828 million people worldwide. In the US, type 2 diabetes affects approximately 1 in 6 adults.

Observations: Risk factors for type 2 diabetes include older age, family history, overweight or obesity, physical inactivity, gestational diabetes, Hispanic ethnicity, and American Indian or Alaska Native, Asian, or Black race. Diabetes is diagnosed if fasting plasma glucose is greater than or equal to 126 mg/dL, hemoglobin A1C is greater than or equal to 6.5%, or 2-hour glucose during 75-g oral glucose tolerance testing is greater than or equal to 200 mg/dL. Approximately one-third of adults with type 2 diabetes have cardiovascular disease and 10.1% have severe vision difficulty or blindness. The prevalence of type 2 diabetes is 39.2% among patients with kidney failure. Although weight management is an important component of treatment for type 2 diabetes, no specific diet has been proven to be most effective for improving health outcomes. Physical activity can reduce hemoglobin A1C by 0.4% to 1.0% and improve cardiovascular risk factors (ie, hypertension and dyslipidemia). Randomized clinical trials have reported absolute reductions in microvascular disease (3.5%), such as retinopathy and nephropathy, myocardial infarction (3.3%-6.2%), and mortality (2.7%-4.9%), with intensive glucose-lowering strategies (hemoglobin A1C <7%) vs conventional treatment 2 decades after trial completion. First-line medications for type 2 diabetes include metformin and, in patients with cardiovascular or kidney comorbidities or at high cardiovascular risk, glucagon-like peptide-1 receptor agonists (GLP-1RAs) or sodium-glucose cotransporter 2 inhibitors (SGLT2is). Common add-on medications include dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1RAs, dipeptidyl peptidase-4 inhibitors, sulfonylureas, and thiazolidinediones. Approximately one-third of patients with type 2 diabetes require treatment with insulin during their lifetime. Several randomized clinical trials have demonstrated benefits of specific SGLT2i and GLP-1RA medications compared with placebo for atherosclerotic cardiovascular disease (12%-26% risk reduction), heart failure (18%-25% risk reduction), and kidney disease (24%-39% risk reduction) over 2 to 5 years. Most trial participants with type 2 diabetes were taking metformin. High-potency GLP-1RA and dual GIP/GLP-1RA medications result in weight loss of greater than 5% in most individuals with type 2 diabetes, and weight loss may exceed 10%.

Conclusions: Type 2 diabetes affects up to 14% of the global population and is associated with preventable long-term complications, such as cardiovascular disease, kidney failure, vision loss, and increased mortality. In addition to lifestyle modifications including diet, exercise, and weight management, metformin is generally first-line therapy for attainment of hemoglobin A1C targets. For individuals with type 2 diabetes and cardiovascular or kidney disease or at high cardiovascular risk, guidelines recommend early treatment with SGLT2i and/or GLP-1RA medications.

Author/s:

Rita R Kalyani, Joshua J Neumiller, Nisa M Maruthur, Deborah J Wexler

Aortic valve replacement versus conservative treatment in asymptomatic severe aortic stenosis: long-term follow-up of the AVATAR trial

Alex Haga — Tue, 08 Oct 2024 17:36:11 +0000

Date Added:

October 8, 2024

Journal/Publication:

European Heart Journal

Publication Date:

September 1, 2024

URL:

Aortic valve replacement versus conservative treatment in asymptomatic severe aortic stenosis: long-term follow-up of the AVATAR trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1093/eurheartj/ehae585

Keywords

PMID (1):

39217448

MeSH

Aortic Valve

Stroke Volume

Kaplan-Meier Estimate

Avatar

Aortic Valve Stenosis

myocardial infarction

heart failure

Contrary to prior recommendations, it looks like surgical repair of severely stenotic aortic valves produces better results when done early. James W. Mold, MD, MPH

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Background and aims: The question of when and how to treat truly asymptomatic patients with severe aortic stenosis (AS) and normal left ventricular (LV) systolic function is still subject to debate and ongoing research. Here, the results of extended follow-up of the AVATAR trial are reported (NCT02436655, clinical trials.gov).

Methods: The AVATAR trial randomly assigned patients with severe, asymptomatic AS and LV ejection fraction ≥50% to undergo either early surgical aortic valve replacement (AVR) or conservative treatment with watchful waiting strategy. All patients had negative exercise stress testing. The primary hypothesis was that early AVR will reduce a primary composite endpoint comprising all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure (HF), as compared to conservative treatment strategy.

Results: A total of 157 low-risk patients (mean age 67 years, 57% men, mean Society of Thoracic Surgeons score 1.7%) were randomly allocated to either early AVR group (n=78) or conservative treatment group (n=79). In an intention-to-treat analysis, after a median follow-up of 63 months, the primary composite endpoint outcome event occurred in 18/78 patients (23.1%) in the early surgery group and in 37/79 patients (46.8%) in the conservative treatment group (hazard ratio [HR] early surgery vs. conservative treatment 0.42; 95% confidence interval [CI] 0.24-0.73, p=0.002). The Kaplan-Meier estimates for individual endpoints of all-cause death and HF hospitalization were significantly lower in the early surgery compared with the conservative group (HR 0.44; 95% CI 0.23-0.85, p=0.012 for all-cause death, and HR 0.21; 95% CI 0.06-0.73, p=0.007 for HF hospitalizations).

Conclusions: The extended follow-up of the AVATAR trial demonstrates better clinical outcomes with early surgical AVR in truly asymptomatic patients with severe AS and normal LV ejection fraction compared with patients treated with conservative management on watchful waiting.

Author/s:

Marko Banovic, Svetozar Putnik, Bruno R Da Costa, Martin Penicka, Marek A Deja, Martin Kotrc

Demystifying breast cancer

Aubrey Delammermore — Sat, 15 Jul 2023 05:00:00 +0000

Date Added:

July 15, 2023

Journal/Publication:

Canadian Family Physician

Publisher:

College of Family Physicians of Canada

Publication Date:

July 1, 2023

Issue:

Volume:

Pages:

473-476

URL:

Demystifying breast cancer

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.6907473

Keywords

PMID (1):

37451990

MeSH

patients

breast neoplasms

Combined Modality Therapy

Humans

female

A concise summary of the types of breast cancer and their treatment. James W. Mold, MD, MPH

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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.

Neutropenia

Aubrey Delammermore — Sat, 07 Jan 2023 06:00:00 +0000

Date Added:

January 7, 2023

Journal/Publication:

Canadian Medical Association Journal

Publisher:

CMA Impact Inc

Publication Date:

December 19, 2022

Issue:

Volume:

194

Pages:

E1689

URL:

Neutropenia

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.220499

Keywords

PMID (1):

36535676

MeSH

referral and consultation

A concise summary of the causes and evaluation of neutropenia. James W. Mold, MD, MPH

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»Neutropenia is seen in 5%–10% of healthy people
Based on absolute neutrophil count, neutropenia is commonly defined as
mild (1.0–1.5 × 109
/L), moderate (0.5–0.9 × 109
/L) or severe (< 0.5 × 109
/L).1
However, the reference interval is specific to the population. Mild asymptomatic neutropenia per the above definition is common in people of subSaharan African, Arab or West Indian ancestry,2
and is strongly associated
with the Duffy-null phenotype of red blood cells that protects against
Plasmodium vivax malaria.
2 Common causes include medications, infection, nutritional
deficiency, malignant disease and autoimmune disease
Causes include underproduction (e.g., myelodysplastic syndrome),
immune-mediated destruction or redistribution of neutrophils to the
endothelium and reticuloendothelial system. Antithyroid, anti-infective
and psychotropic drugs, as well as chemotherapy, are causes of druginduced neutropenia.3,4 Transient neutropenia may occur after acute
viral infection and typically resolves within 2 weeks. Joint swelling, rash,
bony pain, splenomegaly or lymphadenopathy may suggest malignant or
autoimmune disease.
3Investigation should begin with a repeat complete blood count
and peripheral blood film
Neutropenia is often identified incidentally. Persistent and unexplained
neutropenia requires further work-up for a range of causes, including
chronic viral infection (e.g., hepatitis, HIV) and nutritional deficiency (e.g.,
vitamin B12) (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/
cmaj.220499/tab-related-content).
4 Treatment of mild neutropenia should be directed at the
underlying cause
Patients with mild neutropenia are not at substantially increased risk of
infection.5
The neutrophil count should be checked every 3–6 months for
at least 1 year to rule out progression to more severe neutropenia.
5 Patients with moderate-to-severe neutropenia for more than
6 months should be referred to a specialist
Patients with recurrent or severe bacterial infections (e.g., requiring hospital admission or intravenous antibiotics), abnormalities on peripheral blood
films (e.g., circulating blasts, hairy cells, large granular lymphocytes, dysplastic granulocytes) or pancytopenia also warrant referral to a specialist
(e.g., hematologist, internist, pediatrician).1
Febrile neutropenia (absolute
neutrophil count < 0.5 × 109
/L and an oral temperature > 38.0°C sustained
over 1 h) requires immediate treatment with broad-spectrum antibiotics.

Author/s:

Mithoowani, Siraj, Cameron, L., Crowther, M. A.

Migraine — Treatment and Preventive Therapies

Aubrey Delammermore — Thu, 13 Oct 2022 05:00:00 +0000

Date Added:

October 13, 2022

Journal/Publication:

New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

October 13, 2022

Issue:

e35

Volume:

387

URL:

Migraine — Treatment and Preventive Therapies

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Video

DOI (1):

10.1056/NEJMp2212749

Keywords

migraine treatment

preventative therapies

injectable monoclonal antibodies

patient care

treatment

MeSH

Patient-Centered Care

An 11 minute video review of our current understanding of migraine and an update on newer therapies. James W. Mold, MD, MPH

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In this instructional video, Drs. Cynthia Armand and Elizabeth Loder discuss the clinical presentation and pathophysiology of migraine and treatment options for patients.

This video provides essential and useful information for any clinician caring for patients with this common condition. Newer acute and preventive therapies — including triptans, gepants, ditans, and injectable monoclonal antibodies — are discussed, as are the importance of a patient-centered approach and the need to tackle challenges of access to these newer agents.

Author/s:

Armand, C.E., Loder, E., Ropper, A. H.

Chronic anal pain: A review of causes, diagnosis, and treatment

Saige Blanchard — Tue, 14 Jun 2022 05:00:00 +0000

Date Added:

June 14, 2022

Journal/Publication:

Cleveland Clinic Journal of Medicine

Publisher:

Cleveland Clinic Journal of Medicine

Publication Date:

June 1, 2022

Issue:

Volume:

Pages:

336-343

URL:

Chronic anal pain: A review of causes, diagnosis, and treatment

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3949/ccjm.89a.21102

Keywords

PMID (1):

35649568

MeSH

Levator syndrome

Pudendal Neuralgia

diagnostic tests, routine

Syndrome

pain

A nice review of the causes of chronic anal pain. James W. Mold, MD, MPH

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Chronic anal pain is diffi cult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. This review identifi es 3 main diagnostic
categories for chronic anal pain: local causes, functional
anorectal pain, and neuropathic pain syndromes. Conditions covered within these categories include proctalgia
fugax, levator ani syndrome, pudendal neuralgia, and coccygodynia. The signs, symptoms, relevant diagnostic tests,
and main treatments for each condition are reviewed.

Author/s:

Knowles, C. H., Cohen, R. C.

Comparison of Amitriptyline and US Food and Drug Administration–Approved Treatments for Fibromyalgia A Systematic Review and Network Meta-analysis

Saige Blanchard — Tue, 07 Jun 2022 05:00:00 +0000

Date Added:

June 7, 2022

Journal/Publication:

JAMA Network Open

Publisher:

JAMA Network Open

Publication Date:

May 19, 2022

Issue:

Volume:

URL:

Comparison of Amitriptyline and US Food and Drug Administration–Approved Treatments for Fibromyalgia A Systematic Review and Network Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2022.12939

Keywords

PMID (1):

35587348

MeSH

duloxetine hydrochloride

A review of studies of medications used to treat fibromyalgia. Results of interest mainly involved amitriptyline and duloxetine (Cymbalta). James W. Mold, MD, MPH

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Importance: Amitriptyline is an established medication used off-label for the treatment of fibromyalgia, but pregabalin, duloxetine, and milnacipran are the only pharmacological agents approved by the US Food and Drug Administration (FDA) to treat fibromyalgia.

Objective: To investigate the comparative effectiveness and acceptability associated with pharmacological treatment options for fibromyalgia.

Data sources: Searches of PubMed/MEDLINE, Cochrane Library, Embase, and Clinicaltrials.gov were conducted on November 20, 2018, and updated on July 29, 2020.

Study selection: Randomized clinical trials (RCTs) comparing amitriptyline or any FDA-approved doses of investigated drugs.

Data extraction and synthesis: This study follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Four independent reviewers extracted data using a standardized data extraction sheet and assessed quality of RCTs. A random-effects bayesian network meta-analysis (NMA) was conducted. Data were analyzed from August 2020 to January 2021.

Main outcomes and measures: Comparative effectiveness and acceptability (defined as discontinuation of treatment owing to adverse drug reactions) associated with amitriptyline (off-label), pregabalin, duloxetine, and milnacipran (on-label) in reducing fibromyalgia symptoms. The following doses were compared: 60-mg and 120-mg duloxetine; 150-mg, 300-mg, 450-mg, and 600-mg pregabalin; 100-mg and 200-mg milnacipran; and amitriptyline. Effect sizes are reported as standardized mean differences (SMDs) for continuous outcomes and odds ratios (ORs) for dichotomous outcomes with 95% credible intervals (95% CrIs). Findings were considered statistically significant when the 95% CrI did not include the null value (0 for SMD and 1 for OR). Relative treatment ranking using the surface under the cumulative ranking curve (SUCRA) was also evaluated.

Results: A total of 36 studies (11 930 patients) were included. The mean (SD) age of patients was 48.4 (10.4) years, and 11 261 patients (94.4%) were women. Compared with placebo, amitriptyline was associated with reduced sleep disturbances (SMD, -0.97; 95% CrI, -1.10 to -0.83), fatigue (SMD, -0.64; 95% CrI, -0.75 to -0.53), and improved quality of life (SMD, -0.80; 95% CrI, -0.94 to -0.65). Duloxetine 120 mg was associated with the highest improvement in pain (SMD, -0.33; 95% CrI, -0.36 to -0.30) and depression (SMD, -0.25; 95% CrI, -0.32 to -0.17) vs placebo. All treatments were associated with inferior acceptability (higher dropout rate) than placebo, except amitriptyline (OR, 0.78; 95% CrI, 0.31 to 1.66). According to the SUCRA-based relative ranking of treatments, duloxetine 120 mg was associated with higher efficacy for treating pain and depression, while amitriptyline was associated with higher efficacy for improving sleep, fatigue, and overall quality of life.

Conclusions and relevance: These findings suggest that clinicians should consider how treatments could be tailored to individual symptoms, weighing the benefits and acceptability, when prescribing medications to patients with fibromyalgia.

Author/s:

Farag, H. M., Yunusa, I., Goswami, H., Sultan, I., Doucette, J. A., Eguale, T.

Nonspecific Low Back Pain

Saige Blanchard — Tue, 10 May 2022 05:00:00 +0000

Date Added:

May 10, 2022

Journal/Publication:

New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

May 5, 2022

Issue:

Volume:

386

Pages:

1732-1740

URL:

Nonspecific Low Back Pain

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1056/NEJMcp2032396

Keywords

back pain

Nonspecific Low Back Pain

MeSH

A review of what we think we know about non-specific low back pain. James W. Mold, MD, MPH

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Low back pain typically defined as pain below the costal margin and above the inferior gluteal folds with or without leg pain 1 is worldwide the most prevalent and most disabling of the conditions that are considered to benefit from rehabilitation 2 In a systematic review that included 165 studies from 54 countries the mean point prevalence of low back pain in the general adult population was approximately 12 with a higher prevalence among persons 40 years of age or older and among women the lifetime prevalence was approximately 40 3 Low back pain is classified as specific pain and other symptoms that are caused by specific pathophysiological mechanisms of nonspinal or spinal origin or nonspecific back pain with or without leg pain without a clear nociceptive-specific cause 4 Nonspinal causes of specific low back pain include hip conditions diseases of the pelvic organs e g prostatitis and endometriosis and vascular e g aortic aneurysm or systemic disorders spinal causes include herniated disk spinal stenosis fracture tumor infection and axial spondyloarthritis Lumbar disorders with radicular pain due to nerve-root involvement have a higher prevalence 5 to 10 than other spinal causes the two most frequent causes of such back pain are herniated disk and spinal stenosis 5 The overall prevalence of the other spinal disorders is low among patients with acute low back pain For example among 1172 patients who presented to primary care clinicians in Australia with acute low back pain only 11 0 9 were found to have serious spinal conditions mostly fractures during 1 year of follow-up 6 The authors of a Dutch study that involved primary care patients reported axial spondyloarthritis in almost one quarter of adults 20 to 45 years of age who presented with chronic low back pain 7 although these findings have not been replicated In contrast to low back pain caused by specific identifiable causes nonspecific low back pain probably develops from the interaction of biologic psychological and social factors 4 and it accounts for approximately 80 to 90 of all cases of low back pain 1 Low back pain is usually classified according to pain duration as acute 6 weeks subacute 6 to 12 weeks or chronic 12 weeks

Author/s:

Chiarotto, A., Koes, B. W.

Oral Antiviral Medications for COVID-19

Saige Blanchard — Tue, 10 May 2022 05:00:00 +0000

Date Added:

May 10, 2022

Journal/Publication:

Journal of the American Medical Association

Publisher:

American Medical Association

Publication Date:

April 25, 2022

URL:

Oral Antiviral Medications for COVID-19

Type:

Patient Education Materials

Format:

Poster

DOI (1):

10.1001/jama.2022.6876

Keywords

MeSH

PF-07321332 and ritonavir drug combination

Information for patients on the appropriate use of oral antivirals for COVID. James W. Mold, MD, MPH

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Twonewantiviralmedications, ritonavir-boostednirmatrelvir (Paxlovid,
ie, nirmatrelvir-ritonavir) and molnupiravir (Lagevrio), are currently
available in theUS underemergency useauthorization. These 2 drugs
areauthorized for treatmentofpatientswithmild tomoderateCOVID19 who are not currently hospitalized but are at high risk of developingseveredisease.Nirmatrelvir-ritonavirandmolnupiravirareapproved
for use only within 5 days of onset of COVID-19 symptoms.
Nirmatrelvir-ritonavir andmolnupiravir should be considered for
patients with symptoms of COVID-19 who test positive for SARSCoV-2 and either are an older adult (aged 65 years or older) or are
aged 12 years or older with an underlying condition that increases
risk of severe outcomes of COVID-19 (such as cancer, heart disease,
diabetes, and obesity).

Author/s:

Petty, L. A., Malani, P. N.

Diagnosis and Treatment of Pulmonary Arterial Hypertension: A Review

Saige Blanchard — Thu, 14 Apr 2022 05:00:00 +0000

Date Added:

April 14, 2022

Journal/Publication:

Journal of the American Medical Association

Publisher:

American Medical Association

Publication Date:

April 12, 2022

Issue:

327

Volume:

Pages:

1379-1391

URL:

Diagnosis and Treatment of Pulmonary Arterial Hypertension: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2022.4402

Keywords

Pulmonary Arterial Hypertension

diagnosis

treatment

PAH

PMID (1):

35412560

MeSH

Humans

infant, newborn

Hypertension, Pulmonary

treprostinil

Epoprostenol

A review of the management of patients with pulmonary hypertension. James W. Mold, MD, MPH

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Importance: Pulmonary arterial hypertension (PAH) is a subtype of pulmonary hypertension (PH), characterized by pulmonary arterial remodeling. The prevalence of PAH is approximately 10.6 cases per 1 million adults in the US. Untreated, PAH progresses to right heart failure and death.

Observations: Pulmonary hypertension is defined by a mean pulmonary artery pressure greater than 20 mm Hg and is classified into 5 clinical groups based on etiology, pathophysiology, and treatment. Pulmonary arterial hypertension is 1 of the 5 groups of PH and is hemodynamically defined by right heart catheterization demonstrating a mean pulmonary artery pressure greater than 20 mm Hg, a pulmonary artery wedge pressure of 15 mm Hg or lower, and a pulmonary vascular resistance of 3 Wood units or greater. Pulmonary arterial hypertension is further divided into subgroups based on underlying etiology, consisting of idiopathic PAH, heritable PAH, drug- and toxin-associated PAH, pulmonary veno-occlusive disease, PAH in long-term responders to calcium channel blockers, and persistent PH of the newborn, as well as PAH associated with other medical conditions including connective tissue disease, HIV, and congenital heart disease. Early presenting symptoms are nonspecific and typically consist of dyspnea on exertion and fatigue. Currently approved therapy for PAH consists of drugs that enhance the nitric oxide-cyclic guanosine monophosphate biological pathway (sildenafil, tadalafil, or riociguat), prostacyclin pathway agonists (epoprostenol or treprostinil), and endothelin pathway antagonists (bosentan and ambrisentan). With these PAH-specific therapies, 5-year survival has improved from 34% in 1991 to more than 60% in 2015. Current treatment consists of combination drug therapy that targets more than 1 biological pathway, such as the nitric oxide-cyclic guanosine monophosphate and endothelin pathways (eg, ambrisentan and tadalafil), and has shown demonstrable improvement in morbidity and mortality compared with the previous conventional single-pathway targeted monotherapy.

Conclusions and relevance: Pulmonary arterial hypertension affects an estimated 10.6 per 1 million adults in the US and, without treatment, typically progresses to right heart failure and death. First-line therapy with drug combinations that target multiple biological pathways are associated with improved survival.

Author/s:

Ruopp, N. F., Cockrill, B. A.

Antiseizure Medications for Adults With Epilepsy: A Review

Saige Blanchard — Thu, 14 Apr 2022 05:00:00 +0000

Date Added:

April 14, 2022

Journal/Publication:

Journal of the American Medical Association

Publisher:

American Medical Association

Publication Date:

April 5, 2022

Issue:

327

Volume:

Pages:

1269-1281

URL:

Antiseizure Medications for Adults With Epilepsy: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2022.3880

Keywords

Epilepsy

Antiseizure Medication

Seizures

treatment

PMID (1):

35380580

MeSH

A review of antiepileptic medications for adults. James W. Mold, MD, MPH

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Importance: Epilepsy affects approximately 65 million people worldwide. Persistent seizures are associated with a 20% to 40% risk of bodily injuries (eg, fractures, burns, concussions) over 12-month follow-up. The primary goal of epilepsy treatment is to eliminate seizures while minimizing adverse effects of antiseizure drugs (ASDs).

Observations: An epileptic seizure is defined as a sudden occurrence of transient signs and symptoms caused by abnormal and excessive or synchronous neuronal activity in the brain. Focal and generalized epilepsy are the 2 most frequent types of epilepsy; diagnosis is based on the type of seizures. There are 26 US Food and Drug Administration-approved medications for epilepsy, of which 24 have similar antiseizure efficacy for focal epilepsy and 9 have similar efficacy for generalized epilepsy. The decision to initiate an ASD should be individualized, but should be strongly considered after 2 unprovoked seizures or after 1 unprovoked seizure that occurred during sleep and/or in the presence of epileptiform activity on an electroencephalogram and/or in the presence of a structural lesion on the brain magnetic resonance imaging. The ASDs must be selected based on the seizure and epilepsy types, the epilepsy syndrome, and the adverse effects associated with the drug. For focal epilepsy, oxcarbazepine and lamotrigine are first-line therapy, while levetiracetam can be also considered if there is no history of psychiatric disorder. For generalized epilepsy, the selection of the ASD is based on the type of epilepsy syndrome and the patient's sex, age, and psychiatric history. Seizure freedom is achieved in approximately 60% to 70% of all patients. A total of 25% to 50% of patients also experience neurologic, psychiatric, cognitive, or medical disorders, such as mood, anxiety, and attention deficit disorders and migraines. For these patients, selecting an ASD should consider the presence of these disorders and concomitant use of medications to treat them. ASDs with cytochrome P450 enzyme-inducing properties (eg, carbamazepine, phenytoin) may worsen comorbid coronary and cerebrovascular disease by causing hyperlipidemia and accelerating the metabolism of concomitant drugs used for their treatment. They can also facilitate the development of osteopenia and osteoporosis.

Conclusions and relevance: Epilepsy affects approximately 65 million people worldwide and is associated with increased rates of bodily injuries and mortality when not optimally treated. For focal and generalized epilepsy, selection of ASDs should consider the seizure and epilepsy types and epilepsy syndrome, as well as the patient's age and sex, comorbidities, and potential drug interactions.

Author/s:

Kanner, A. M., Bicchi, M. M.

Midodrine for the Prevention of Vasovagal Syncope : A Randomized Clinical Trial

Saige Blanchard — Fri, 06 Aug 2021 05:00:00 +0000

Date Added:

August 6, 2021

Journal/Publication:

Annals of Internal Medicine

Publisher:

ACP

Publication Date:

August 3, 2021

URL:

Midodrine for the Prevention of Vasovagal Syncope : A Randomized Clinical Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

https://doi.org/10.7326/m20-5415

Keywords

PMID (1):

34339231

MeSH

Hospitals, University

Midodrine can be a helpful treatment for patients with recurrent vasovagal syncope. James W. Mold, MD, MPH

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Background: Recurrent vasovagal syncope is common, responds poorly to treatment, and causes physical trauma and poor quality of life. Midodrine prevents hypotension and syncope during tilt tests in patients with vasovagal syncope.

Objective: To determine whether midodrine can prevent vasovagal syncope in usual clinical conditions.

Design: Randomized, double-blind, placebo-controlled clinical trial. (ClinicalTrials.gov: NCT01456481).

Setting: 25 university hospitals in Canada, the United States, Mexico, and the United Kingdom.

Patients: Patients with recurrent vasovagal syncope and no serious comorbid conditions.

Intervention: Patients were randomly assigned 1:1 to placebo or midodrine and followed for 12 months.

Measurements: The primary outcome measure was the proportion of patients with at least 1 syncope episode during follow-up.

Results: The study included 133 patients who had had a median of 6 syncope episodes in the prior year (median age, 32 years; 73% female). Compared with patients receiving placebo, fewer patients receiving midodrine had at least 1 syncope episode (28 of 66 [42%] vs. 41 of 67 [61%]). The relative risk was 0.69 (95% CI, 0.49 to 0.97; P = 0.035). The absolute risk reduction was 19 percentage points (CI, 2 to 36 percentage points), and the number needed to treat to prevent 1 patient from having syncope was 5.3 (CI, 2.8 to 47.6). The time to first syncope was longer with midodrine (hazard ratio, 0.59 [CI, 0.37 to 0.96]; P = 0.035; log-rank P = 0.031). Adverse effects were similar in both groups.

Limitation: Small study size, young and healthy patients, relatively short observation period, and high proportion of patients from 1 center.

Conclusion: Midodrine can reduce the recurrence of syncope in healthy, younger patients with a high syncope burden."

Author/s:

Sheldon, R., Faris, P., Tang, A., Ayala-Paredes, F., Guzman, J., Marquez, M., Morillo, C. A., Krahn, A. D., Kus, T., Ritchie, D., Safdar, S., Maxey, C., Raj, S. R.

Sexually Transmitted Infections Treatment Guidelines, 2021

Saige Blanchard — Fri, 23 Jul 2021 05:00:00 +0000

Date Added:

July 23, 2021

Journal/Publication:

Morbidity and Mortality Weekly Report

Publisher:

Centers for Disease Control and Prevention

Publication Date:

July 23, 2021

Issue:

Volume:

Pages:

1-187

URL:

Sexually Transmitted Infections Treatment Guidelines, 2021

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

Sexually Transmitted Infection

MeSH

sexually transmitted diseases

Mycoplasma genitalium

neisseria gonorrhoeae

Pelvic Inflammatory Disease

Sexual and Gender Minorities

CDC 2021 Guidance for Treatment of Sexually Transmitted Infections. James W. Mold, MD, MPH

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The term “sexually transmitted infection” (STI) refers to a pathogen that causes infection through sexual contact, whereas the term “sexually transmitted disease” (STD) refers to a recognizable disease state that has developed from an infection. Physicians and other health care providers have a crucial role in preventing and treating STIs. These guidelines are intended to assist with that effort. Although the guidelines emphasize treatment, prevention strategies and diagnostic recommendations also are discussed.

This report updates Sexually Transmitted Diseases Treatment Guidelines, 2015 (1) and should be regarded as a source of clinical guidance rather than prescriptive standards. Health care providers should always consider the clinical circumstances of each person in the context of local disease prevalence. These guidelines are applicable to any patient care setting that serves persons at risk for STIs, including family planning clinics, HIV care clinics, correctional health care settings, private physicians’ offices, Federally Qualified Health Centers, clinics for adolescent care, and other primary care facilities. These guidelines are focused on treatment and counseling and do not address other community services and interventions that are essential to STI and HIV prevention efforts.

These STI treatment guidelines complement Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020 (2) regarding quality clinical services for STIs in primary care and STD specialty care settings. This guidance specifies operational determinants of quality services in various clinical settings, describes on-site treatment and partner services, and indicates when STI-related conditions should be managed through consultation with or referral to a specialist.

Author/s:

Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J. M., Bolan, G. A.

Adverse Events Associated With the Addition of Aspirin to Direct Oral Anticoagulant Therapy Without a Clear Indication

Saige Blanchard — Tue, 08 Jun 2021 05:00:00 +0000

Date Added:

June 8, 2021

Journal/Publication:

Journal of the American Medical Association

Publisher:

American Medical Association

Publication Date:

June 1, 2021

Issue:

Volume:

181

Pages:

817-824

URL:

Adverse Events Associated With the Addition of Aspirin to Direct Oral Anticoagulant Therapy Without a Clear Indication

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamainternmed.2021.1197

Keywords

aspirin

anticoagulant therapy

treatment

heart-valve replacement

thrombosis

PMID (1):

33871544

MeSH

Patients at risk for thrombotic events almost never require the combination of a DOAC and low-dose aspirin. Those taking both are at significantly increased risk of bleeding and no reduction in thrombosis. James W. Mold, MD, MPH

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Importance: It is unclear how many patients treated with a direct oral anticoagulant (DOAC) are using concomitant acetylsalicylic acid (ASA, or aspirin) and how this affects clinical outcomes.

Objective: To evaluate the frequency and outcomes of prescription of concomitant ASA and DOAC therapy for patients with atrial fibrillation (AF) or venous thromboembolic disease (VTE).

Design, setting, and participants: This registry-based cohort study took place at 4 anticoagulation clinics in Michigan from January 2015 to December 2019. Eligible participants were adults undergoing treatment with a DOAC for AF or VTE, without a recent myocardial infarction (MI) or history of heart valve replacement, with at least 3 months of follow-up.

Exposures: Use of ASA concomitant with DOAC therapy.

Main outcomes and measures: Rates of bleeding (any, nonmajor, major), rates of thrombosis (stroke, VTE, MI), emergency department visits, hospitalizations, and death.

Results: Of the study cohort of 3280 patients (1673 [51.0%] men; mean [SD] age 68.2 [13.3] years), 1107 (33.8%) patients without a clear indication for ASA were being treated with DOACs and ASA. Two propensity score-matched cohorts, each with 1047 patients, were analyzed (DOAC plus ASA and DOAC only). Patients were followed up for a mean (SD) of 20.9 (19.0) months. Patients taking DOAC and ASA experienced more bleeding events compared with DOAC monotherapy (26.0 bleeds vs 31.6 bleeds per 100 patient years, P = .01). Specifically, patients undergoing combination therapy had significantly higher rates of nonmajor bleeding (26.1 bleeds vs 21.7 bleeds per 100 patient years, P = .02) compared with DOAC monotherapy. Major bleeding rates were similar between the 2 cohorts. Thrombotic event rates were also similar between the cohorts (2.5 events vs 2.3 events per 100 patient years for patients treated with DOAC and ASA compared with DOAC monotherapy, P = .80). Patients were more often hospitalized while undergoing combination therapy (9.1 vs 6.5 admissions per 100 patient years, P = .02).

Conclusion and relevance: Nearly one-third of patients with AF and/or VTE who were treated with a DOAC received ASA without a clear indication. Compared with DOAC monotherapy, concurrent DOAC and ASA use was associated with increased bleeding and hospitalizations but similar observed thrombosis rate. Future research should identify and deprescribe ASA for patients when the risk exceeds the anticipated benefit.

Author/s:

Schaefer, J. K., Errickson, J., Li, Y., Kong, X., Alexandris-Souphis, T., Ali, M. A., Decamillo, D., Haymart, B., Kaatz, S., Kline-Rogers, E., Kozlowski, J. H., Krol, G. D., Shankar, S, R., Sood, S. L., Froehlich, J. B., Barnes, G. D.