Transcript 1 - RCRMC Family Medicine Residency

Drugs and AAFP
DYSLIPIDEMIA
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Lots of patients are asking if they should stop taking niacin (Niaspan, etc) for dyslipidemia.
It's all due to the new study showing that adding niacin to a statin does NOT improve
cardiovascular outcomes...and might increase strokes.
This is a surprise.
We're accustomed to adding niacin to a statin to raise HDL...and further lower LDL and
triglycerides.
But this might not be helping as much as we thought.
Adding niacin doesn't seem to improve OUTCOMES...in patients with heart disease and an LDL
already treated to 70 mg/dL.
Some experts say this study shows that LDL trumps HDL.
Others say this is further evidence of the possible benefit of statins' non-lipid-lowering effects.
But...and it's a big but...this doesn't tell us whether niacin is beneficial for the many patients who
are NOT at their LDL goal.
Stick with the current guidelines and focus on lowering LDL.
Emphasize a healthy diet and regular physical activity.
Maximize statins first...they have the best evidence for reducing mortality and cardiac risk.
But don't use simvastatin 80 mg/day...myopathy risk is too high. If simvastatin (Zocor, etc) 40 mg
isn't enough, go to atorvastatin (Lipitor) 40 mg or rosuvastatin (Crestor) 10 to 20 mg.
If patients can't reach their LDL goal on a statin alone, discuss the pros and cons of adding niacin,
ezetimibe (Zetia), or a bile acid sequestrant.
Explain that combo therapy lowers LDL more. But the cons are the extra cost...potential adverse
effects...and lack of good evidence that the combos improve outcomes.
Don't jump to conclusions about niacin and strokes. Niacin has been around a long time...and has
never been linked to strokes.
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DIABETES
Some people are confusing the news about Avandia and Actos.
Avandia products will all but disappear...due to cardiac concerns.
After November 18th, prescribers and patients will have to be enrolled in
theAvandia-Rosiglitazone Medicines Access Program to prescribe or get
rosiglitazone.
Patients will qualify only if they're already on rosiglitazone...or can't use
other diabetes meds, including pioglitazone (Actos, etc).
Retail pharmacies will no longer carry rosiglitazone...patients will have to
get it by mail from a specialty pharmacy.
Switch any patients still on rosiglitazone to another med.
The Actos situation is different. Pioglitazone sales are being suspended in
France and Germany...and scrutinized here...due to concerns about bladder
cancer.
But it's premature to abandon pioglitazone.
Any risk is very small...possibly 3 extra cases of bladder cancer for every
10,000 patients per year on pioglitazone long-term.
For now, discuss this possible risk with patients...and don't use pioglitazone
in patients who have or had bladder cancer.
ANTIDEPRESSANTS
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You'll see Viibryd (VI-brid) marketed as a new "dual-acting"
serotonergic antidepressant.
Viibryd (vilazodone) inhibits serotonin reuptake like SSRIs...plus it's
also a partial serotonin agonist.
The company hoped Viibryd would be more effective than SSRIs.
But it's not.
Viibryd doesn't work better than fluoxetine or citalopram...and it
causes more GI side effects.
You might also hear that Viibryd has a low risk of sexual side
effects...but it's too soon to tell if this is true.
Viibryd comes in a starter kit to help minimize GI problems. If you
start a patient on Viibryd, give 10 mg/day for 7 days...20 mg/day for 7
days...then 40 mg/day thereafter.
Don't exceed 20 mg/day if patients are taking a strong CYP3A4
inhibitor...ketoconazole, clarithromycin, ritonavir, etc.
Tell patients to take Viibryd with food for adequate absorption...and
caution about possible nausea, diarrhea, insomnia, and dizziness.
Viibryd will cost $150 per month. Continue to use an SSRI or SNRI
first for depression.
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Singular
Patients are hearing that Singulair is "as good as" inhaled corticosteroids or
long-acting beta-agonists for asthma.
This comes from a new study that suggests leukotriene antagonists are
"essentially equivalent" to using an inhaled steroid first...or to adding a longacting beta-agonist second in adults.
Now some patients are hoping to replace a twice-daily inhaler with a oncedaily pill. Plus, Singulair will be generic next year.
Help patients put the new info in perspective.
A leukotriene antagonist seems to work as well to improve quality of life
after two MONTHS...but not necessarily after two YEARS.
Continue to start with an inhaled steroid for persistent asthma in MOST
patients. These have the most evidence for improving outcomes.
Emphasize adherence. Advise patients that inhaled steroids need to be used
regularly to prevent exacerbations.
If a low-dose inhaled steroid isn't enough, increase the steroid dose...or add a
long-acting beta-agonist. In kids, also consider
adding Singulair (montelukast)...it has anti-inflammatory effects and
symptoms in kids are often due to inflammation.
Save leukotriene antagonists as monotherapy for patients who have trouble
using or adhering to inhaled steroids
RESPIRATORY / ALLERGY
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You'll hear about Daliresp (DA-li-resp), a new oral tablet for severe
COPD in patients with chronic bronchitis.
Daliresp (roflumilast) is the first in a new class of oral
phosphodiesterase 4 inhibitors. It works by reducing lung
inflammation.
It's added to the usual bronchodilator therapy to decrease
exacerbations...but only for severe, chronic COPD.
That's because the modest benefit may not outweigh its risks.
Daliresp is linked to insomnia, weight loss, depression, and possibly
suicide. There's also concern about a possible increased cancer
risk...but tell patients this hasn't been proven.
Daliresp 500 mcg/day costs about $200 per month.
Maximize bronchodilators before trying Daliresp.
Watch for interactions with CYP3A4 drugs. CYP3A4 inhibitors
(erythromycin, etc) increase Daliresp levels and can increase adverse
effects. Strong CYP3A4 inducers (phenytoin, etc) can decrease
efficacy.
Caution patients about possible GI side effects...diarrhea, nausea,
abdominal pain, etc...especially in the first few weeks.
Warn them to report serious mood or behavioral changes.
CLOSTRIDIUM DIFFICILE DIARRHEA
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Reps will promote that the new oral drug Dificid (fidaxomicin)
for Clostridium difficile diarrhea is superior to oral vancomycin.
That's because Dificid works at least as well as vanco to control C.
diff...but seems to have a lower risk of recurrence.
There's one less recurrence within one month for every 10 patients
treated with Dificid instead of oral vancomycin.
But recurrence rates are similar if patients have the more virulent
strain of C. diff. About one-third of cases in the U.S. are now caused
by this BI/NAP1/027 strain.
Dificid costs about $2800 for a standard 10-day course.
Vancomycin 125 mg QID for 10 days costs about $1300 for the
capsules...and $60 or less if you give the injectable orally.
Continue to use oral metronidazole 500 mg TID for 10 to 14 days for
mild to moderate infections...and oral vancomycin 125 mg QID for 10
to 14 days for severe infections.
Consider using Dificid 200 mg twice daily for 10 days to minimize
recurrence risk...or if fewer doses will improve adherence.
Emphasize the importance of handwashing with soap and water.
Explain that alcohol gels don't kill C. diff spores.
RESTLESS LEGS SYNDROME
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You'll hear reps talking about Horizant for restless legs syndrome.
It's an extended-release version of gabapentin enacarbil...which is converted to plain
gabapentin in the body. This formulation increases and prolongs its absorption.
But there's no evidence it works better or is better tolerated. And it costs about $120 a
month...compared to $6 to $95 for gabapentin.
Consider Rx meds for patients who need them for restless legs.
Dopamine agonists (pramipexole, ropinirole) are often tried first for daily symptoms.
Tell patients to take them about 2 hours before bedtime...but caution about nausea,
dizziness, sleepiness, and impulse control problems such as compulsive gambling or
shopping.
Give half the dose earlier if symptoms worsen or occur earlier.
Carbidopa/levodopa can help with intermittent symptoms. Have patients take one-half
or one 25/100 mg tab before bedtime...or a 25/100 mg CR tab if the effects wear off
before morning.
Gabapentin can help patients who don't tolerate dopamine agonists...or whose
symptoms include pain or unpleasant sensations.
Start with gabapentin 100 to 300 mg up to two hours before bedtime...titrating up to
about 1800 mg/day if needed.
For doses over 600 mg/day, have patients take half the dose in the late afternoon and
the rest up to 2 hours before bedtime.
Horizant dosing is different...give 600 mg at 5 PM with food.
Keep in mind that Horizant and gabapentin dosing is not equivalent. Retitrate doses if
you need to switch.
Positive-pressure ventilation is
not necessary in the first _______
of cardiac arrest.
A) 2 to 4 min
B) 5 to 7 min
C) 10 to 12 min
D) 15 to 17 min
Answer
• C) 10 to 12 min
Which of the following drugs
have been proven effective in the
management of cardiac arrest?
A) Vasopressors
B) Antiarrhythmics
C) Amiodarone
D) None of the above
Answer
• D) None of the above
The "4 Cs" of modern management of cardiac arrest
include which of the following?Cardiac
compressions
Cardioversion
Cooling
Cardiac catheterization
Calcium
A) 1,2,3,4
B) 1,2,4,5
C) 1,3,4,5
D) 1,2,3,5
Answer
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Cardiac compressions
Cardioversion
Cooling
Cardiac catheterization
Most cases of unstable
bradycardia are not related to
acute myocardial infarction.
A) True
B) False
Answer
• A) True
Electrocardiographic findings of
hyperkalemia include which of
the following?
A) Peaked T wave
B) Widening of QRS complex
C) Flattening and eventual loss
of P wave
D) All the above
Answer
• D) All the above
Which of the following statements about
adenosine is correct?
A) All patients with supraventricular
tachycardia (SVT) respond to adenosine
B) Less than 50% of patients with VT
respond to adenosine
C) Most patients with adenosine-sensitive VT
do not have underlying cardiac disease
D) Adenosine is reliable for distinguishing
VT from SVT
Answer
• C) Most patients with adenosine-sensitive
VT do not have underlying cardiac disease
Accelerated idioventricular
rhythm does not generally require
treatment.
A) True
B) False
Answer
• A) True
All the following statements
about amiodarone are true,except:
A) Effective for premature
ventricular contractions
B) Contraindicated in pregnancy
C) Shortens QT interval
D) Efficacy for treatment of
stable VT approximately equal to
that of lidocaine
Answer
• C) Shortens QT interval
Which of the following has been
shown to be more sensitive than
common sense in predicting
which patients with syncope will
have serious adverse outcomes?
A) Boston Syncope Criteria
B) Short-Term Prognosis of
Syncope (StePS) study
C) San Francisco Syncope Rule
D) None of the above
Answer
• D) None of the above
Patients who have taken clopidogrel
within _______ of coronary bypass
surgery are at risk for increased
bleeding complications, increased
need for packed cell transfusions,
and increased perioperative
mortality.
A) 2 wk
B) 5 days
C) 8 days
D) 10 days
Answer
• B) 5 days
MANAGEMENT OF ACUTE
ASTHMA EXACERBATIONS
Which one of the following is a
characteristic of a mild asthma
exacerbation? (check one)
A. Dyspnea at rest.
B. Perspiration.
C. Peak expiratory flow of less than 40
percent of personal best.
D. Dyspnea only with activity.
Answer
• D. Dyspnea only with activity.
Which one of the following home-based treatments
has been shown to produce modest benefits in
children with frequent acute asthma
exacerbations? (check one)
A. A short course of oral prednisolone at the onset
of worsening symptoms.
B. Increased dosage of a long-acting beta2 agonist.
C. Increased dosage of inhaled corticosteroids.
D. Continuous beta2 agonist treatment.
Answer
• A. A short course of oral prednisolone at the
onset of worsening symptoms.
Which of the following are considered
risk factors for repeat emergency
department visits for acute asthma
symptoms in children? (check all that
apply)
A. Age older than 10 years.
B. Age younger than two years.
C. Public health insurance.
D. Hispanic ethnicity.
Answer
• B. Age younger than two years.
C. Public health insurance.
D. Hispanic ethnicity.
Clinical giudlines
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Inhaled short-acting beta2 agonists are the cornerstones of treatment for acute asthma.
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An inhaler with a spacer is equivalent to nebulized short-acting beta2 agonist therapy in
children and adults.
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Continuous beta2 agonist administration reduces hospital admissions in patients with
severe acute asthma.
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Inhaled anticholinergic medication improves lung function and decreases hospitalization
in school-age children with severe asthma exacerbations.
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When multiple doses are used in combination with short-acting beta2agonists
Intravenous magnesium sulfate increases lung function and decreases hospitalizations in
children with an acute asthma exacerbation.
A
The administration of systemic corticosteroids within one hour of emergency
department presentation decreases the need for hospitalization.
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Largest effect noted in patients with severe asthma
Oral and parenteral corticosteroids are equally effective in preventing hospital
admission in children.
B
Diagnosis
• Asthma exacerbations can be classified as mild, moderate, severe, or
life threatening
• Criteria for severity are based on symptoms and physical examination
parameters, as well as lung function and oxygen saturation.
• Although no single parameter has been identified to assess
exacerbation severity, lung function is a useful method of assessment,
with a PEF of 40 percent or less of predicted function indicating a
severe attack in patients five years or older.
• The most useful signs for determining the severity of an asthma
exacerbation in children younger than five years, or any child unable to
perform a PEF, include the use of accessory muscles of respiration,
chest wall retractions, tachypnea greater than 60 breaths per minute,
cyanosis, and the presence of inspiratory and expiratory wheezing.
• For all patients, pulse oximetry on room air is a useful initial
assessment. An oxygen saturation of less than 92 to 94 percent one
hour after beginning standard treatment is a strong predictor of the
need for hospitalization
Management
• HOME TREATMENT
• Early treatment is the most effective strategy for managing asthma
exacerbations.
• It is essential to teach patients how to monitor signs and symptoms,
and take appropriate action.
• Patients who have a written asthma action plan and appropriate
medication can often manage mild exacerbations at home.
• Key components of an asthma action plan that have reduced
emergency department visits and hospitalization include standard
written instructions; criteria based on symptoms or PEF (compared
with personal best) to trigger action; two to three action points; and
individualized, written instructions on the use of inhaled or oral
corticosteroids.
• Patients at risk of asthma-related death may need more intensive
treatment in a monitored setting at the first sign of an exacerbation.
These patients should have an asthma action plan that emphasizes
early communication with their physician.
Magnessium
• The addition of intravenous magnesium sulfate to standard
therapy has been studied in adults and children with
divergent results. In adults with severe exacerbations of
asthma (PEF of 25 to 30 percent or less of predicted
function), intravenous magnesium sulfate therapy resulted
in slightly better lung function but no change in rates of
hospitalization.
• In children one to 18 years of age, intravenous magnesium
sulfate (25 to 100 mg per kg) has been demonstrated to
significantly increase lung function and to decrease
hospitalizations.
• Nebulized magnesium sulfate has a weak effect on
respiratory function and hospital admission rates in adults,
and no effect on either outcome in children
Steroids
• The administration of systemic corticosteroids (500 mg hydrocortisone
sodium succinate injection [Solu-Cortef] or 125 mg
methylprednisolone sodium succinate injection [Solu-Medrol] in
adults, or 1 to 2 mg per kg of prednisone or prednisolone in children
one to 18 years of age) within one hour of emergency department
presentation decreases the need for hospitalization.In a Cochrane
review, the most pronounced effect occurred in patients with severe
exacerbations.
• Oral and parenteral corticosteroids are equally effective in preventing
hospital admission in children, but only parenteral corticosteroids have
been studied in adults.
• There is insufficient evidence to recommend the use of inhaled
corticosteroids in place of or in conjunction with systemic
corticosteroids at the time of discharge from the emergency
department. Inhaled corticosteroids do not prevent relapse of
symptoms requiring admission or improve quality of life or symptom
scores
POSTDISCHARGE CARE
• Patients sent home from the emergency department with
systemic corticosteroids (a five- to 10-day nontapering
course of 50- to 100-mg prednisone per day in adults) have
decreased relapse of asthma symptoms, future
hospitalizations, and use of short-acting
beta2 agonists. Although seven to 10 days is the usual
treatment duration for oral corticosteroids, three days of
therapy (1 mg per kg of prednisone) has been shown to be
as effective as five days for the complete resolution of
symptoms within one week in children two to 15 years of
age.
• There are insufficient data to recommend the initiation of
montelukast in place of oral corticosteroids or the use of
inhaled corticosteroids in combination with oral
corticosteroids at the time of discharge to prevent a relapse
of asthma symptoms.
DIAGNOSIS AND TREATMENT OF LICHEN
PLANUS
Which one of the following statements about the
treatment of oral lichen planus is correct? (check
one)
A. Complete resolution is difficult to achieve.
B. Systemic corticosteroids are first-line treatments.
C. Carbon-dioxide laser evaporation is ineffective.
D. Adrenal suppression is a common complication
of topical steroid use.
Answer
• A. Complete resolution is difficult to
achieve.
A patient presents with hypertrophic
pruritic lichen planus on the ankles.
Which one of the following is the most
appropriate treatment? (check one)
A. Intralesional triamcinolone
(Kenalog).
B. Acitretin (Soriatane).
C. Topical lidocaine (Xylocaine).
D. Topical pimecrolimus (Elidel).
Answer
• A. Intralesional triamcinolone (Kenalog).
Which of the following are
appropriate topical treatments for
genital lichen planus? (check all
that apply)
A. Triamcinolone (Triderm).
B. Tacrolimus (Protopic).
C. Clobetasol (Temovate).
D. Aloe vera gel.
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Lichen planus
Lichen planus is a chronic, inflammatory, autoimmune disease that affects the skin, oral
mucosa, genital mucosa, scalp, and nails.
Lichen planus lesions are described using the six P's (planar [flat-topped], purple, polygonal,
pruritic, papules, plaques).
Onset is usually acute, affecting the flexor surfaces of the wrists, forearms, and legs.
The lesions are often covered by lacy, reticular, white lines known as Wickham striae.
Classic cases of lichen planus may be diagnosed clinically, but a 4-mm punch biopsy is often
helpful and is required for more atypical cases.
High-potency topical corticosteroids are first-line therapy for all forms of lichen planus,
including cutaneous, genital, and mucosal erosive lesions.
In addition to clobetasol, topical tacrolimus appears to be an effective treatment for
vulvovaginal lichen planus.
Topical corticosteroids are also first-line therapy for mucosal erosive lichen planus.
Systemic corticosteroids should be considered for severe, widespread lichen planus involving
oral, cutaneous, or genital sites.
Referral to a dermatologist for systemic therapy with acitretin (an expensive and toxic oral
retinoid) or an oral immunosuppressant should be considered for patients with severe lichen
planus that does not respond to topical treatment.
Lichen planus may resolve spontaneously within one to two years, although recurrences are
common.
However, lichen planus on mucous membranes may be more persistent and resistant to
treatment.
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Clinical
Recomendations
High-potency topical corticosteroids should be first-line treatments for
all forms of lichen planus.
B
Topical calcineurin inhibitors, such as tacrolimus (Protopic) and
pimecrolimus (Elidel), should be used as second-line therapies to treat
genital and oral lichen planus.
B
Intralesional triamcinolone acetonide (Kenalog), 5 to 10 mg per mL
injection, should be used to treat hypertrophic lichen planus.
B
Three to six weeks of oral prednisone therapy should be used to treat
severe, widespread lichen planus (tapered course, 30 to 60 mg per day
starting dose).
B
Answer
• A. Triamcinolone (Triderm).
B. Tacrolimus (Protopic).
C. Clobetasol (Temovate).
D. Aloe vera gel.
Diagnosis
• Lichen planus can be diagnosed clinically in classic cases, although
biopsy is often helpful to confirm the diagnosis and is required for
more atypical presentations.
• A 4-mm punch biopsy should be adequate on the skin or in the mouth.
• The histology shows a characteristic “saw-tooth” pattern of epidermal
hyperplasia; hyperparakeratosis with thickening of the granular cell
layer; and vacuolar alteration of the basal layer of the epidermis, with
an intense infiltration (mainly T cells) at the dermal-epidermal
junction.
• A 4-mm punch biopsy of perilesional skin for direct
immunofluorescence may be added to the workup when bullous
lesions, pemphigus, or bullous pemphigoid is present. Tables
2 and 3 present the differential diagnosis of cutaneous and oral lichen
planus.
Treatment
• CUTANEOUS LICHEN PLANUS
• Cutaneous lichen planus may resolve spontaneously within one to two
years, although lichen planus affecting mucous membranes may be
more persistent and resistant to treatment.
• Recurrences are common, even with treatment.
• High-potency topical corticosteroids are first-line therapy for
cutaneous lichen planus.
• Oral antihistamines (e.g., hydroxyzine [Vistaril]) may be used to
control pruritus.
• Hypertrophic lesions are treated with intralesional triamcinolone
acetonide (Kenalog), 5 to 10 mg per mL injection (0.5 to 1 mL per 2cm lesion)
OUTPATIENT APPROACH TO
PALPITATIONS
Which one of the following is the
most common cardiac structural
cause of palpitations? (check one)
A. Bicuspid aortic valve.
B. Pulmonary stenosis.
C. Atrial septal defect.
D. Mitral valve prolapse.
Answer
• D. Mitral valve prolapse.
Which one of the following statements about
supraventricular tachycardia is correct? (check one)
A. Wide complex supraventricular tachycardia is
easily distinguished from ventricular tachycardia.
B. Vagal maneuvers should be used for treatment
only as a last resort.
C. Intravenous adenosine (Adenocard) is an
effective option for drug therapy.
D. Verapamil should never be used in patients with
refractory episodes.
Answer
• C. Intravenous adenosine (Adenocard) is an
effective option for drug therapy.
Which of the following are independent
predictors of an arrhythmic cause of
palpitations? (check all that apply)
A. Visible neck pulsations.
B. Palpitations at work.
C. Palpitations affecting sleep.
D. Duration of palpitation less than five
minutes.
Answer
• A. Visible neck pulsations.
B. Palpitations at work.
C. Palpitations affecting sleep
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Palpitations
Palpitations are a common problem seen in family medicine; most are of cardiac
origin, although an underlying psychiatric disorder, such as anxiety, is also
common.
Even if a psychiatric comorbidity does exist, it should not be assumed that
palpitations are of a noncardiac etiology.
Discerning cardiac from noncardiac causes is important given the potential risk of
sudden death in those with an underlying cardiac etiology.
History and physical examination followed by targeted diagnostic testing are
necessary to distinguish a cardiac cause from other causes of palpitations.
Standard 12-lead electrocardiography is an essential initial diagnostic test.
Cardiac imaging is recommended if history, physical examination, or
electrocardiography suggests structural heart disease.
An intermittent event (loop) monitor is preferred for documenting cardiac
arrhythmias, particularly when they occur infrequently.
Ventricular and atrial premature contractions are common cardiac causes of
palpitations; prognostic significance is dictated by the extent of underlying
structural heart disease.
Atrial fibrillation is the most common arrhythmia resulting in hospitalization; such
patients are at increased risk of stroke.
Patients with supraventricular tachycardia, long QT syndrome, ventricular
tachycardia, or palpitations associated with syncope should be referred to a
cardiologist.
Clinical Recommendations
• All patients presenting with palpitations should be
evaluated for a cardiac cause.
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• A positive history or abnormal results on physical
examination or electrocardiography should prompt
evaluation for structural heart disease.
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• Supraventricular tachycardia with aberrant conduction may
be difficult to distinguish from ventricular tachycardia. In
the setting of hemodynamic instability or history of heart
disease, ventricular tachycardia should be considered.
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Selected Other Causes of PalpitationsAlcohol
Anemia
Anxiety
Beta-blocker withdrawal
Caffeine
Cocaine
Exercise
Fever
Food poisoning Hypoglycemia
Hypovolemia
Mastocytosis
Medications (see Table 5)
Nicotine
Paget disease
Pheochromocytoma
Pregnancy
Stress
Thyroid disorders
History and Physical Examination
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Discerning cardiac from noncardiac causes is important, given the potential risk of
sudden death in those with an underlying cardiac etiology.
All patients presenting with palpitations should be evaluated for a cardiac cause.
A history of panic attacks or anxiety disorder points to a psychiatric cause,4 whereas a
family history of hyperthyroidism suggests a thyroid disorder.
Important cardiac causes, such as long QT syndrome, have a heritable component,
underscoring the value of a meticulous family history.
Physicians should ask about the context of palpitations, noting that cardiac causes may
occur either at rest (e.g., vagally mediated premature ventricular beats) or with exertion
(e.g., dehydration exacerbating mitral valve prolapse).
Because most patients presenting with palpitations are asymptomatic at the time of the
visit, the examination is focused primarily on uncovering abnormalities that may
indicate structural heart disease or arrhythmia.A positive history or abnormal results on
physical examination or electrocardiography (ECG) should prompt evaluation for
structural heart disease.
Physicians should assess for pulse irregularity, murmurs, point of apical impulse, or
presence of a pulse discrepancy as seen in coarctation of the aorta (a pulse rate at the
wrist that is lower than that at the apex of the heart)
LONG QT SYNDROME
• Long QT syndrome is characterized by a prolonged QT
interval on ECG: more than 460 msec for women and more
than 440 msec for men.
• In addition to palpitations, patients with long QT syndrome
often experience syncope and have an increased risk of
cardiac arrest.
• Patients with long QT syndrome should be referred to a
cardiologist.
• Medications can cause an acquired long QT syndrome,
which is more common than familial QT prolongation.
• Physical and emotional stress are common triggers, with
resultant life-threatening torsades de pointes.
• Beta blockade may be appropriate in some forms.
• Implantation of a cardiac defibrillator is recommended in
those at risk of sudden cardiac death
• Selected Medications and Drug Classes Associated with Long QT
SyndromeAmphetamines
• Antiarrhythmics (e.g., amiodarone [Cordarone], disopyramide
[Norpace], procainamide, quinidine, sotalol [Betapace])
• Anticholinergics
• Antihistamines (e.g., diphenhydramine [Benadryl], hydroxyzine
[Vistaril])
• Decongestants
• Diuretics
• Fluoroquinolone antibiotics
• Macrolide antibiotics
• Phenothiazines
• Protease inhibitors
• Selective serotonin reuptake inhibitors
• Sympathomimetics
• Tricyclic antidepressants
• Vasodilators
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WOLFF-PARKINSON-WHITE
SYNDROME
Wolff-Parkinson-White (WPW) syndrome is a preexcitation syndrome characterized by
electrical impulses traveling along an accessory pathway, thereby triggering ventricular
excitation before the normal impulse arrives.
The most common disturbance in those with WPW syndrome is atrioventricular nodal
reentrant tachycardia, accounting for 95 percent of such cases.6
These patients often present with a heart rate of more than 250 beats per minute, which
can result in life-threatening hypotension due to decreased ventricular filling time.
Although medical management is sometimes used, catheter ablation is now the standard
of care in patients with WPW syndrome.
Patients with WPW syndrome who present with rapid AF and wide complex
tachycardia warrant judicious treatment selection.
In such patients, atrioventricular nodal blocking agents may cause degeneration of the
rhythm and further hemodynamic instability, which may be recognized by careful
interpretation of the ECG.
Office Management of Early Pregnancy Loss
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The management of early pregnancy loss used to be based largely in the hospital
setting, but it has shifted to the outpatient setting, allowing women to remain under
the care of their family physician throughout the miscarriage process.
Up to 15 percent of recognized pregnancies end in miscarriage, and as many as 80
percent of miscarriages occur in the first trimester, with chromosomal
abnormalities as the leading cause.
In general, no interventions have been proven to prevent miscarriage; occasionally
women can modify their risk factors or receive treatment for relevant medical
conditions.
Unless products of conception are seen, the diagnosis of miscarriage is made with
ultrasonography and, when ultrasonography is not available or is nondiagnostic,
with measurement of beta subunit of human chorionic gonadotropin levels.
Management options for early pregnancy loss include expectant management,
medical management with misoprostol, and uterine aspiration. Expectant
management is highly effective for the treatment of incomplete abortion, whereas
misoprostol and uterine aspiration are more effective for the management of
anembryonic gestation and embryonic demise. Misoprostol in a dose of 800 mcg
administered vaginally is effective and well-tolerated.
Compared with dilation and curettage in the operating room, uterine aspiration is
the preferred procedure for early pregnancy loss; aspiration is equally safe,
quicker to perform, more cost-effective, and amenable to use in the primary care
setting. All management options are equally safe; thus, patient preference should
guide treatment choice.
Clinical Recomendations
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Transvaginal ultrasonography is a reliable way to differentiate between viable and nonviable
pregnancies and should be performed when early pregnancy loss is suspected.
C
Because better mental health outcomes result when patient preferences for treatment are respected
and because all treatment options are safe, expectant management, medical management with
misoprostol (Cytotec), and uterine aspiration should be offered to women for the treatment of early
pregnancy loss.
A
Given that expectant management is up to 90 percent effective, it is a reasonable first-line option for
incomplete abortion.
B
Compared with expectant management, medical management with misoprostol hastens completed
abortion, especially in cases of anembryonic gestation and embryonic demise.
A
Compared with dilation and curettage in the operating room, uterine aspiration is the preferred
procedure for early pregnancy loss because aspiration is equally safe, quicker to perform, more costeffective, and amenable to use in the primary care setting.
A
There is insufficient evidence to recommend routine antibiotic prophylaxis following uterine
aspiration.
C
Women experiencing early pregnancy loss should be reassured that subsequent fertility is not
adversely affected by any of the three treatment options (expectant care, medical management with
misoprostol, or uterine aspiration).
B
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EXPECTANT
MANAGEMENT
Many women will first elect to take a “wait and see” approach in hopes that they will
complete their miscarriage without intervention.
For incomplete abortion, the success rate of this approach is up to 90 percent, although
it may take weeks for complete passage of the tissue.
A follow-up appointment to assess completion of the miscarriage and to process the
experience is important.
A repeat ultrasonography showing the absence of a previously documented pregnancy or
an 80 percent drop in the β-hCG level one week following the passage of tissue
confirms completion.
If using β-hCG levels, there is no need to follow them to zero unless ectopic pregnancy
has not been reliably excluded.
However, for cases in which an intrauterine pregnancy has not been documented, it is
prudent to follow β-hCG levels to resolution because ectopic pregnancies can present
with declining β-hCG levels.
In the absence of hemorrhage or infection, there is no limit to how long it is safe to wait
for the miscarriage to complete naturally.
If a patient decides that she wants the process to be over, however, she can switch from
expectant care to medical management or an aspiration procedure at any point.
OFFICE MANAGEMENT OF EARLY
PREGNANCY LOSS
A patient with a newly diagnosed pregnancy and a
previous miscarriage at five weeks' gestation has
been diagnosed with a threatened abortion. Which
one of the following measures may effectively
prevent miscarriage? (check one)
A. Bed rest.
B. Vitamin supplementation.
C. Progestogen use.
D. Uterine muscle relaxants.
E. None of the above.
Answer
• E. None of the above.
A pregnant patient with vaginal spotting has no
visible pregnancy on transvaginal ultrasonography
and an initial beta subunit of human chorionic
gonadotropin (β-hCG) level of 600 mIU per mL. She
has a level of 1,100 mIU per mL 48 hours later. Her
third β-hCG level, measured another 48 hours later,
is 2,500 mIU per mL. This is suggestive of which
one of the following? (check one)
A. An ectopic pregnancy.
B. Early pregnancy failure.
C. A viable pregnancy.
D. Completed abortion.
Answer
• C. A viable pregnancy.
A patient in stable condition chooses expectant management
after confirmation of an intrauterine embryonic demise. In
regard to this patient, which of the following statements are
correct? (check one)
A. Her β-hCG levels should be followed to zero.
B. She can safely switch to medical management at any
time.
C. She should be given a course of antibiotics.
D. She should have an aspiration procedure if she has not
passed tissue within two weeks of diagnosis.
Answer
• B. She can safely switch to medical
management at any time.
COCHRANE FOR CLINICIANS: PUTTING
EVIDENCE INTO PRACTICE
PROBIOTICS FOR PERSISTENT DIARRHEA
IN CHILDREN
Probiotics have been shown to be beneficial for
treating which of the following conditions? (check
all that apply)
A. Irritable bowel syndrome.
B. Acute pancreatitis.
C. Acute diarrhea.
D. Persistent diarrhea.
Answer
• A. Irritable bowel syndrome.
C. Acute diarrhea.
D. Persistent diarrhea.
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Asthma
Asthma exacerbations can be classified as mild, moderate, severe, or life threatening.
Criteria for exacerbation severity are based on symptoms and physical examination
parameters, as well as lung function and oxygen saturation.
In patients with a peak expiratory flow of 50 to 79 percent of their personal best, up to two
treatments of two to six inhalations of short-acting beta2 agonists 20 minutes apart followed by
a reassessment of peak expiratory flow and symptoms may be safely employed at home.
Administration using a hand-held metered-dose inhaler with a spacer device is at least
equivalent to nebulized beta2 agonist therapy in children and adults.
In the ambulatory and emergency department settings, the goals of treatment are correction of
severe hypoxemia, rapid reversal of airflow obstruction, and reduction of the risk of relapse.
Multiple doses of inhaled anticholinergic medication combined with beta2 agonists improve
lung function and decrease hospitalization in school-age children with severe asthma
exacerbations.
Intravenous magnesium sulfate has been shown to significantly increase lung function and
decrease the necessity of hospitalization in children.
The administration of systemic corticosteroids within one hour of emergency department
presentation decreases the need for hospitalization, with the most pronounced effect in patients
with severe exacerbations.
Airway inflammation can persist for days to weeks after an acute attack; therefore, more
intensive treatment should be continued after discharge until symptoms and peak expiratory
flow return to baseline.