Archive for the ‘Blog’ Category

Blood Pressure: How Low Do You Go? Our Four Cents from Dr. Thornton and Dr. Wallace

Wednesday, December 23, 2015 // Blood Pressure, Medication

Choosing the optimal blood pressure target to shoot for in managing hypertension requires that we apply the art of medicine, rather than just a cookbook approach. Over recent years, we have gotten dizzy keeping up with various recommendations which have swung back and forth between lower versus higher blood pressure goals. Last year a Joint National Committee on Hypertension recommended higher blood pressure targets: <140/90, but <150/90 in adults over 60 years old. Now we have a new large study published in November (the SPRINT study) which has caused the pendulum to swing back toward a goal of lower blood pressures, specifically in individuals at least 50 years old who already have cardiovascular disease, or who have at least one risk factor for developing it. The SPRINT study found that treating these patients aggressively, with a goal of achieving a systolic (top number) blood pressure <120, rather than to a more conservative target of <140, resulted in a significant decrease in the risk of cardiovascular events such as stroke or heart attack, and of death in general.

As usual, nothing is ever black or white. Getting to the lower target required more blood pressure medications (an average of 3, vs. 2 for the higher target), which increases the chance of side effects. The target of <120 also caused more incidence of blood pressure going too low, as one might expect. This increases the possibility of dizziness and falls which can be devastating, especially in our older patients.

So we must once again apply the art of medicine, treating each patient as an individual, and keeping new information in mind as we attempt to balance the risk of medication side effects against the risk of future adverse events.

Below is a summary published in Journal Watch of the findings of the SPRINT study, followed by some published comments:
SPRINT: A Trial of Intensive Blood Pressure Lowering Allan S. Brett, MD reviewing The SPRINT Research Group. N Engl J Med 2015 Nov 9. Chobanian AV. N Engl J Med 2015 Nov 9.Allan S. Brett, MD

Allan S. Brett, MDTreating to a systolic target of 120 mm Hg lowered the incidence of adverse cardiovascular events in a high-risk population. Allan S. Brett, MD

Treating to a systolic target of 120 mm Hg lowered the incidence of adverse cardiovascular events in a high-risk population. Allan S. Brett, MDFor years, clinicians have debated how far to lower blood pressure (BP) in hypertensive patients. The multicenter Systolic Blood Pressure Intervention Trial (SPRINT) now provides some guidance. SPRINT researchers enrolled 9361 patients (age, ≥50) with systolic BP of 130 to 180 mm Hg and high cardiovascular (CV) risk (defined as one or more of these: known symptomatic or asymptomatic CV disease, chronic kidney disease [CKD] with glomerular filtration rate ( a measure of kidney function) [GFR] 20–59 mL/minute/1.73 m2, 10-year Framingham CV risk ≥15%, or age ≥75). Patients with diabetes and stroke were excluded. Patients were randomized to either intensive or standard treatment (systolic BP targets, 120 or 140 mm Hg, respectively). The protocol included general guidelines for choice of antihypertensive agents, but researchers were permitted discretion in choosing drug regimens. Diuretics, angiotensin-converting–enzyme inhibitors or angiotensin-receptor blockers, calcium-channel blockers, and β-blockers were used extensively. During the trial, intensive- and

For years, clinicians have debated how far to lower blood pressure (BP) in hypertensive patients. The multicenter Systolic Blood Pressure Intervention Trial (SPRINT) now provides some guidance. SPRINT researchers enrolled 9361 patients (age, ≥50) with systolic BP of 130 to 180 mm Hg and high cardiovascular (CV) risk (defined as one or more of these: known symptomatic or asymptomatic CV disease, chronic kidney disease [CKD] with glomerular filtration rate ( a measure of kidney function) [GFR] 20–59 mL/minute/1.73 m2, 10-year Framingham CV risk ≥15%, or age ≥75). Patients with diabetes and stroke were excluded. Patients were randomized to either intensive or standard treatment (systolic BP targets, 120 or 140 mm Hg, respectively). The protocol included general guidelines for choice of antihypertensive agents, but researchers were permitted discretion in choosing drug regimens. Diuretics, angiotensin-converting–enzyme inhibitors or angiotensin-receptor blockers, calcium-channel blockers, and β-blockers were used extensively. During the trial, intensive- and standard-treatment patients required averages of three and two drugs, respectively. The trial was terminated early after median follow-up of 3.3 years, during which participants’ average systolic BPs were 121.5 mm Hg and 134.6 mm Hg in the intensive- and standard-treatment groups, respectively. The primary composite outcome (myocardial infarction [MI], non-MI acute coronary syndrome, stroke, heart failure, or CV-related death) occurred in 5.2% of intensive-treatment patients and 6.8% of standard-treatment patients (P<0.001). Relative reductions in this outcome were similar in subgroups of patients with CKD and of patients older than 75. Two individual components of the composite outcome were significantly lower with intensive treatment — heart failure (1.3% vs. 2.1%) and CV-related death (0.8% vs. 1.4%). All-cause mortality also was significantly lower with intensive treatment (3.3% vs. 4.5%).Several serious adverse events were significantly more common with intensive than with standard treatment: Incidences of hypotension (low blood pressure), syncope (passing out), and electrolyte abnormalities were each about 1 percentage point higher, and incidence of acute kidney injury was about 2 percentage points higher. Among patients without CKD at baseline, the incidence of a >30% decline in GFR was significantly greater with intensive treatment (3.8% vs. 1.1%).Comment — General Medicine Allan S. Brett, MD

Comment — General Medicine Allan S. Brett, MDSPRINT has demonstrated that aiming for a systolic BP of 120 mm Hg can lower the rate of adverse cardiovascular events; to prevent 1 event, 61 patients had to be treated for 3.3 years. Keep in mind that SPRINT was limited to middle-aged and older patients at above-average CV risk and that diabetic patients were excluded because the ACCORD BP researchers had examined this question (and showed no significant lowering of adverse CV events with intensive treatment; NEJM JW Cardiol Apr 2010 and N Engl J Med 2010; 362:1575). Whether the decline in GFR (kidney function) associated with intensive treatment represents a harmless hemodynamic effect or

SPRINT has demonstrated that aiming for a systolic BP of 120 mm Hg can lower the rate of adverse cardiovascular events; to prevent 1 event, 61 patients had to be treated for 3.3 years. Keep in mind that SPRINT was limited to middle-aged and older patients at above-average CV risk and that diabetic patients were excluded because the ACCORD BP researchers had examined this question (and showed no significant lowering of adverse CV events with intensive treatment; NEJM JW Cardiol Apr 2010 and N Engl J Med 2010; 362:1575). Whether the decline in GFR (kidney function) associated with intensive treatment represents a harmless hemodynamic effect or more-serious renal injury is unclear. Because this trial will change practice, clinicians must understand how BP was measured in the study. At each visit, patients were seated in a quiet area for 5 minutes. Then, BP was recorded by a commercially available automated unit that recorded three readings, separated by several minutes, with no clinician in the room. Decisions were based on the average of the three readings. Other studies have shown that this method of BP measurement yields substantially lower readings than does the single rushed measurement typical in many practices. If SPRINT is applied without attention to proper BP measurement, substantial overtreatment — with a higher rate of adverse events — likely will occur .Finally, note that the average achieved systolic BP in the intensive-treatment group (121.5 mm Hg) remained higher than the 120 mm target. This likely represents judicious balancing by treating clinicians who tried to approximate the 120 mm goal while avoiding side effects and excessive polypharmacy. Thus, an editorialist concludes reasonably that “the results from SPRINT warrant reducing the treatment goal for systolic blood pressure to less than 130 mm Hg” in patients who meet SPRINT’s enrollment criteria. – See more at: http://www.jwatch.org/na39551/2015/11/09/sprint-trial-intensive-blood-pressure-lowering#sthash.lYs1viqL.dpuf

Generalizability of the SPRINT Results

Harlan M. Krumholz, MD,

SM reviewing Bress AP et al. J Am Coll Cardiol 2015 Nov 9.

An analysis of NHANES data shows how many U.S. adults with hypertension meet SPRINT eligibility criteria. Harlan M. Krumholz, MD, SMThe SPRINT trial (N Engl J Med 2015 Nov 9; [e-pub]), which tested a blood pressure goal of <120 mm Hg against the standard goal of <140 mm Hg, was released amid much fanfare, but a relevant question is its generalizability. Non-SPRINT investigators used data from the National Health and Nutrition Examination Survey to estimate the prevalence, number, and characteristics of U.S. adults who would meet SPRINT inclusion criteria.They found that in the years 2007–2012, an estimated 7.6% of U.S. adults (17 million people) — including 16.7% of those with treated hypertension (8 million) and 5.0% of those not being treated (8.5 million) — met SPRINT eligibility criteria. Among all U.S. adults with hypertension, an estimated 20% met eligibility criteria.

Comment : Many Americans meet SPRINT eligibility criteria and might benefit from the blood pressure goal of <120 mm Hg. However, importantly, 5 of 6 people with treated hypertension do not meet the eligibility criteria. Decisions about treatment goals for these patients will be based on greater uncertainty than for the patients who meet the eligibility criteria. – See more at: http://www.jwatch.org/na39586/2015/11/09/generalizability-sprint-results#sthash.V6eg6DGx.dpuf

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Prostate Cancer Screening

Wednesday, December 23, 2015 // Cancer, Prostate

PSA Police?

Screening for prostate cancer is controversial for reasons outlined in this article from the Wall Street Journal, but now the controversy is taking a new turn. The government is becoming more aggressive in determining what high-quality care is. In the past, Medicare and private insurers would not pay for certain tests or medications that were unapproved. Now, Medicare will actually penalize doctors for ordering such tests. This goes way beyond educating the public. It interferes with shared decision making by patients and their doctors.

Doctors Could be Penalized for Ordering This Test

Wall Street Journal
November 20, 2015
By Melinda Beck

Medicare officials are considering a measure that would penalize doctors who order routine prostate-cancer screening tests for their patients, as part of a federal effort to define and reward quality in health-care services.The proposal, which hasn’t been widely publicized, has prompted a flurry of last-minute comments to the Centers for Medicare and Medicaid Services, including more than 200 in the past two days, virtually all in opposition. The official comment period began Oct. 26 and ends Friday.

The proposal, which hasn’t been widely publicized, has prompted a flurry of last-minute comments to the Centers for Medicare and Medicaid Services, including more than 200 in the past two days, virtually all in opposition. The official comment period began Oct. 26 and ends Friday.Many of those commenting said the measure would discourage doctors from discussing the pros and cons of screening for prostate-specific antigen (PSA) with their patients and allowing them to decide, as several major medical groups recommend.

Many of those commenting said the measure would discourage doctors from discussing the pros and cons of screening for prostate-specific antigen (PSA) with their patients and allowing them to decide, as several major medical groups recommend.“PSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,” said David Penson, chair of public policy and practice support for the American Urological Association, which urged CMS to reject the proposal. “To make it a quality measure would say, ‘You’re a poor quality doctor if your patients get this test.’ ”

“PSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,” said David Penson, chair of public policy and practice support for the American Urological Association, which urged CMS to reject the proposal. “To make it a quality measure would say, ‘You’re a poor quality doctor if your patients get this test.’ ”The proposed measure is part of continuing federal efforts to develop ways to identify and reward value in health care. The Obama administration has said it plans to tie 50% of Medicare payments to such quality measures by 2018.

The proposed measure is part of continuing federal efforts to develop ways to identify and reward value in health care. The Obama administration has said it plans to tie 50% of Medicare payments to such quality measures by 2018.Since 2012, the U.S. Preventive Services Task Force has recommended against routine screening for prostate cancer for men of any age on the grounds that the benefits don’t outweigh the harms.

Since 2012, the U.S. Preventive Services Task Force has recommended against routine screening for prostate cancer for men of any age on the grounds that the benefits don’t outweigh the harms.Studies have shown that screening reduces the risk of death from prostate cancers only minimally, if atStudies have shown that screening reduces the risk of death from prostate cancers only minimally, if at all, because most grow so slowly they effectively are harmless.

Yet many men diagnosed with prostate cancer undergo surgery and radiation, which can have lifelong side effects.

Meanwhile, about 28,000 U.S. men die annually from aggressive prostate cancers, often despite getting regular PSA tests and fast treatment. (This is not substantiated).

Both the rate of PSA testing, and diagnoses of early-stage prostate cancer, have declined significantly in the U.S. in recent years, according to studies published in the Journal of the American Medical Association this week. But whether treating fewer cancers early results in more deaths from late-stage prostate cancer later won’t be known for many years.

A CMS official said that as currently drafted, the proposed measure addresses only “non-recommended PSA screenings”—that is, “men who get PSA screening when, under current clinical guidelines, it is not recommended for them.” She said it wouldn’t restrict needed or medically necessary PSA tests.

“Physicians can still order PSA tests if they feel the test is recommended or if the patient requests it,” she said.

The proposal lists some categories of men who would be excluded from the measure, including those with a history of prostate cancer or enlarged prostate, prior elevated PSA levels, or those taking certain medications for prostate issues. It doesn’t mention men at high risk for prostate cancer due to family history or African-American heritage. Some experts say the benefits of screening may outweigh the harms for such patients.

Wanda Flier, president of the American Academy of Family Physicians, which is working with CMS on other quality measures, said it planned to urge the agency to adopt a more flexible measure for PSA screening that would allow for shared decision-making between a patient and physician based on individual circumstances.

“Our goal, as we move to value-based care, is to get to a system that is based on evidence and individual circumstances and not create harm to the patient or undue economic harm to the country,” she said.

Here is the bottom line on prostate cancer screening from the most recent Annals of Internal Medicine:

Clinical Bottom Line: Screening

Screening for prostate cancer and active treatment may prevent some prostate cancer deaths, mostly a decade or more later. However, screening also produces false-negative and false-positive results and over diagnosis. Cancer treatments cause sexual dysfunction in most men and distinct patterns of urinary and bowel symptoms. Therefore, harm is much more likely than benefit. Because men differ in how they weigh these outcomes, a shared decision-making process that reviews benefits and harms is essential to any informed decision to screen. However, providers should recommend against screening for men who have no risk factors and are younger than 50 years, most men older than 69 years, and those with a life expectancy less than 10 years.

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Flu Vaccine

Wednesday, December 16, 2015 // Flu, Vaccines

Everyone over the age of 6 months should get the flu vaccine. It used to be so simple; there was just one flu vaccine.  Now we have high dose, trivalent, quadrivalent, intranasal and intradermal, to name a few.  Here is a list of the vaccines available and their indications:

flu-vaccine

To avoid ordering multiple types of flu vaccine we have chosen the vaccine that would suit the needs of the majority of our patients, the standard dose trivalent vaccine.  Some patients have asked about the high dose vaccine–it contains much more antigen than the standard dose, but studies so far show that it is no more effective, or may be only marginally better, depending on which study one reads.

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Patient Portal Instructions Redux

Wednesday, December 16, 2015 // Patient Portal

These are the instructions for retrieving your blood test results from the secure patient portal.

Here is it how it works:

  1. We collect your personal email address and enter that into our computer system
  2. We register you for the Patient Portal and assign you your own unique PIN.
  3. To complete the registration process, log into the CGM PATIENTPORTAL at https://phr.cgmus.com/. a. Please use Chrome as the web browser of choice for this site.
  4. The first time you access the Patient Portal, you will be required to “Create your account”, which is where you will need your PIN (noted below). a. If you lose your PIN, you may contact your doctor’s office to have it provided to you.
  5. Select “Create your account”, where you will be asked to enter your PIN, the first three letters of your first name, the first three letters of your last name, and your date of birth. a. NOTE: when creating your account or when using the Forgot Password function are the only two times that you need your PIN. Your password is used for login to the portal.
  6. Click “Next”, and you will be asked to create a password for your Patient Portal account.
    1. Enter a Password that you will remember.
    2. If you forget your password, you may select the “Forgot Password?” link on the homepage of the Patient Portal. i. NOTE: Your doctor’s office will not know your password and will not be able to change it for you. You must use the “Forgot Password?” link to recover your password.
  1. Back at the login screen you will enter the following details to login:
    1. Email Address = your personal email address that you provided to your doctor’s office.
    2. Password = the password you just created.
  1. You now have access to the Patient Portal, and you are on your way to communicating directly, and securely, with your doctor! a. NOTE: You may only send messages from the Patient Portal to someone who has a specific secure email address.

Every time we send you a secure message via the Patient Portal, you will receive a notification in your personal email account. This way, you know when you have something new in your Patient Portal in-box. In these emails sent to your personal account, you are provided with the URL/hyperlink to the Patient Portal. Each time you access the Patient Portal (after your initial login) you are asked to login with your personal email address and your password (the password you entered during account creation at first login).

  • The URL for the Patient Portal is https://phr.cgmus.com/.
  • REMEMBER: The Patient Portal is not the place to report to us any emergency concerns. If you are experiencing any emergency, please dial 911. The Patient Portal messages we receive from you will be checked throughout the day on regular business days.
  • We can use the Patient Portal for the following purposes and as applicable:
    • Sending you a summary of your recent office visit
    • Providing you with a URL to review any patient-specific education resources
    • Informing you of other medical items, such as lab results

We look forward to communicating with you on-line!

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New Mammography Guidelines

Wednesday, December 16, 2015 // Women's Health

Here is a summary from the publication Journal Watch:

American Cancer Society Updates Mammography Guidelines for Average-Risk Women
American Cancer Society Updates Mammography Guidelines for Average-Risk WomenRecommendations move closer to those of the USPSTF — but differences remain.
Recommendations move closer to those of the USPSTF — but differences remain.
Andrew M. Kaunitz, MD

Based on input from clinicians, public health specialists, laypeople, and a commissioned review, the American Cancer Society (ACS) has issued its first guideline update since 2003 regarding screening mammography for average-risk women (no personal history of breast cancer, known mutation associated with excess risk, or history of chest wall radiation at a young age). Recommendations are delineated as strong (consensus that the benefits of adhering to the recommendation outweigh undesirable effects) or qualified (clear evidence of benefits but less certainty about benefit–harm balance or women’s preferences that could influence their decisions). The new guidelines are as follows:Age

  • Age 40–44: Optional annual screening mammography (qualified)
  • Age 45: Begin screening (strong)
  • Age 45–54: Annual screening (qualified)
  • Age ≥55: Biennial screening with option to continue annual screens (qualified)
  • Continue screening as long as overall health is good and life expectancy is ≥10 years (qualified).
  • Any age: Clinical breast examination (CBE) for screening is not recommended (qualified).

Comment: The updated ACS recommendations reduce the potential for harms (overdiagnosis and unnecessary additional imaging and biopsies) and move closer to the guidelines of the U.S. Preventive Services Task Force (USPSTF; i.e., begin biennial screening at age 50; NEJM JW Womens Heath Dec 2009 and Ann Intern Med 2009; 151:716).As one editorialist points out, the ACS recommendation to begin screening at age 45 is based on observational comparisons between screened and unscreened cohorts, a type of analysis the USPSTF does not consider because of concerns about bias. The ACS’s recommendation for annual screening in women aged 45–54 is based in part on the findings of a recent study showing that, for premenopausal (but not postmenopausal) women, tumor stage was higher and size larger for screen-detected lesions among women undergoing biennial screens. The ACS recommendation against screening CBE, stemming from the absence of data supporting CBE’s benefits (alone or with screening mammography), represents a dramatic change from the society’s prior stance. Moreover, in leaving their 2003 guidance regarding breast self-examination unchanged, the ACS continues to recommend against this latter practice. Overall, these updated guidelines should result in more women starting screening mammograms later in life as well as opting for biennial screening, meaning fewer lifetime screens. Also, fewer breast examinations during well-woman visits will allow clinicians more time to assess family history and other risk factors for breast cancer, as well as to maintain dialog about screening recommendations. In my practice, I will continue to encourage screening per USPSTF guidance (begin biennial screens at age 50) for my average-risk patients, while recognizing that many will be more comfortable starting screening at an earlier age and annually thereafter. – See more at: http://www.jwatch.org/na39390/2015/10/22/american-cancer-society-updates-mammography-guidelines#sthash.I7aWUyaH.dpuf

My two cents from Dr. Jennifer Wallace:

Previously the standard of practice was for women to have annual mammograms starting at age 40. We now have two agencies who have recommended reduced frequency of screening mammograms for average risk women. The difficulty with screening procedures, as always, is to find the right balance between screening frequently enough to detect problems at an easily curable stage vs. screening too often, leading to further possibly unnecessary testing and anxiety.

Previously the standard of practice was for women to have annual mammograms starting at age 40. We now have two agencies who have recommended reduced frequency of screening mammograms for average risk women. The difficulty with screening procedures, as always, is to find the right balance between screening frequently enough to detect problems at an easily curable stage vs. screening too often, leading to further possibly unnecessary testing and anxiety.

The new recommendations by the American Cancer Society for less frequent mammograms are somewhat “soft”, leaving us a lot of wiggle room. Their recommendations, other than to start screening at age 45, are “qualified”, meaning that the benefits are known, but there is less certainty about whether the harms of screening on the proposed schedule outweigh the benefits. Further, since we have recently started using “3D mammograms”, which are less likely to miss small or early cancers, I wonder if the “benefit vs. harm” calculation could possibly change in favor of annual screening again.

Unfortunately, it may take years before the harms, if any, of the reduced screening are known. I will look forward to finding out those results. Meanwhile, for now I am leaning toward continuing annual mammograms, particularly in women who are taking postmenopausal hormone replacement. As always, I will be open to discussion with my patients about their preferences, and stay open to change as more information becomes available.

Jennifer Wallace MD

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Insurance Conundrum

Wednesday, December 16, 2015 // Insurance

BCBS (Blue Cross Blue Shield) has canceled all their PPO plans in Texas and are only offering HMO plans through the federal website, Healthcare.gov. In addition, other insurers are canceling their PPO products. This will leave patients with more restrictions on the doctors that they are able to see. From our standpoint, HMO’s are less desirable because they require us to obtain authorizations or referrals for our patients to see any other physician. If many of our patients choose HMO’s we will have to hire someone to just take care of the paperwork. It is like having an unfunded mandate from Congress. It increases the hassle factor of obtaining needed care. If you are having difficulty obtaining insurance, I think it makes sense to use an agent. There are a number of independent insurance agencies which have agents who can assist in sorting through all the options. Wortham, Catto and Catto and Sanger and Altgelt all have agents who can assist in this. The key points are: 1) to look at a plan’s website and see if we are on it. It seems logical that we would know every plan that we are on, but that’s not the case given the turmoil in this industry. 2) Look for something that contains the phrase “Open Access”. This generous access to specialists than a traditional HMO.

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New Pneumonia Vaccine Guidelines for Patients Over 65

Friday, January 23, 2015 // News, Vaccines

These recommendations have been in the works for a long time. What the CDC didn’t mention is that Medicare hasn’t decided whether to pay for the PCV13 vaccine or not. Patients anxious to get the vaccine are getting confusing information from pharmacies. Some are trying to give them the PPSV23 when the ask for the PCV13 which goes by the brand name Prevnar. Until the dust settles, I’m not ordering any.

The Advisory Committee on Immunization Practices (ACIP) recommends that the 13-valent pneumococcal conjugate vaccine (PCV13,Prevnar) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23,Pneumovax) should be routinely administered in series to all adults who are at least 65 years of age, the CDC announced last week.

Adults in this age group who have not previously received a pneumococcal vaccine or who do not know their vaccination history should receive a dose of PCV13, followed by a dose of PPSV23 6 to 12 months later. The 2 vaccines should not be administered together, and the minimum acceptable interval between them is 8 weeks, the ACIP said.

Adults in this age group who have previously received 1 or more doses of PPSV23 should receive a dose of PCV13 if they not already done so. This dose should be given at least 1 year after the most recent PPSV23 dose was received. Patients in whom another dose of PPSV23 is indicated should receive it 6 to 12 months after PCV13 and 5 or more years after the most recent dose of PPSV23.

The recommendations were published in the Sept. 19 Morbidity and Mortality Weekly.

 

Other News:

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Vicodin

Friday, January 23, 2015 // Medication, News

Vicodin (hydrocodone/APAP) a potent pain killer has been changed by the Federal government from a Class III drug for which a prescription can be written or called in to a special prescription which can’t be called in and has to be written on a special prescription. This is in an effort to reduce abuse of prescription drugs. There is also a reduction in the number of days for which a prescription can be written. It goes from 180 days to 90 days. A prescription for it will now necessitate a trip to the doctor’s office.

We’ll see how this plan works. It will be challenging for patients with chronic conditions which necessitate the regular use of this medication.

 

Other News:

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Stress Testing

Friday, January 23, 2015 // News

Stress testing may be useful to screen for heart disease, assess exercise tolerance and blood pressure response to exercise, but the American College of Cardiology does not recommend doing it in patients at low risk for coronary artery disease because a positive test, which may indicate underlying heart disease, is more likely to be a false positive in these individuals.  The patient may then have to go through additional testing to prove what isn’t wrong with them.  It may be useful in stratifying risk is patients who have multiple risk factors for heart disease.  I will continue to utilize it in those select individuals.

 

Other News:

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Flu Vaccine

Friday, January 23, 2015 // Flu, News

Most patients have received their flu vaccine by now. Unfortunately, it’s not a great match with the strain that is circulating now as the following article from Journal Watch outlines, but it is all we have available and offers some protection.

 

Flu Vaccine Not a Perfect Match to Circulating Viruses

By Kelly Young Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS Roughly half of the circulating influenza A (H3N2) viruses collected in the U.S. early this flu season are antigenically different from the H3N2 virus included in this year’s vaccine, prompting CDC officials to remind healthcare providers about using neuraminidase inhibitors to treat and prevent influenza. H3N2 has been present in about 90% of influenza-positive tests this flu season. Years with high H3N2 activity tend to see higher flu morbidity and mortality. The World Health Organization recommended components for the Northern Hemisphere vaccine in February. Antigenically drifted H3N2 viruses were detected in March and became more prevalent in September, too late to change the vaccine. “They’re different enough that we’re concerned that protection from vaccination … may be lower than we usually see,” CDC Director Tom Frieden told reporters on Thursday.The CDC is still recommending that people get vaccinated against the flu because it provides partial protection and the B strains are well matched. But Frieden said that if clinicians suspect influenza in high-risk patients, they should start neuraminidase inhibitor treatment without waiting for confirmatory test results. – See more here.

I was very surprised by the recommendation of the Tamiflu-like medications (neuraminidase inhibitors) given recent articles on their lack of efficacy. Again, from Journal Watch.

 

Tamiflu, Relenza Data Show Little Clinical Benefit Against Flu
By Joe Elia

The neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) have only marginal benefits in the treatment and prevention of influenza, a series of BMJ articles concludes. Investigators reviewed documents submitted to regulatory agencies concerning both drugs. Tamiflu data showed it reduced symptom duration by roughly 17 hours but made no difference in hospital admissions or rates of carefully defined pneumonia. Tamiflu increased nausea and vomiting. As prophylaxis, it greatly reduced symptomatic (but not asymptomatic) cases. The Relenza analysis similarly showed a modest reduction in symptom duration (14 hours) and no effect on pneumonia. As prophylaxis, it acted like Tamiflu and had fewer side effects. Editorialists observe that the analyses show “with greater clarity than ever” that the current system for drug regulation is broken. And one commented that, given these results, “it is difficult to conceive that many patients would actively seek treatment.”. NEJM Journal Watch Infectious Diseases associate editor Stephen Baum wrote: “Clean out your medicine cabinet: these reviews call into question the drugs’ efficacy and side effects, as well as the ways in which data were selectively used to promote them.” – See more here

Still, most people who are sick would gladly shorten their sickness by 17 hours. If you have headache, fever and a cough you can call, email or text. Make sure to do it in the first 48 hours. It is not considered good medical practice to prescribe medications for people who are not your patients. It is also a big liability to prescribe drugs with potential side effects for people with whose medical history you are not familiar.. For those reasons I don’t call in Tamiflu for non patients, and recommend calling their physician.

 

 

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