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Obtaining cystatin-C levels useful in chronic kidney disease
SAN FRANCISCO – Routine lab tests for estimating the average glomerular filtration rate (GFR) are too imprecise, according to Michael G. Shlipak, MD.
“If you study 100 patients, the average GFR based on creatinine is going to be pretty close to estimated GFR,” Dr. Shlipak said at the UCSF Annual Advances in Internal Medicine meeting. “But with individual patients, the average GFR is going to be plus or minus 30%, which is a lot. If the estimated GFR is 70 mL/min per 1.73 m2, the real GFR could be between 50 and 90 mL/min per 1.73 m2; so that’s a wide range.”
“The main appeal of the Cockcroft-Gault equation is that you can almost do it in your head, so that’s a real positive,” said Dr. Shlipak, who is also scientific director of the Kidney Health Research Collaborative at the University of California, San Francisco, and professor of internal medicine, epidemiology, and biostatistics at UCSF Medical Center. “The main disadvantage is that it’s really a terrible equation. The Cockcroft-Gault equation is clearly inadequate, as it is standardized to creatinine clearance and very inaccurate, so it should no longer be used. The MDRD and the CKD-EPI are newer equations that are at least validated to real GFR and not creatinine clearance. In our system, the pharmacy uses the Cockcroft-Gault equation, and the lab gives us the MDRD GFR equation, so it’s quite confusing.”
Dr. Shlipak described using estimated GFR in clinical decision making as “better than using just creatinine, because it integrates demographic characteristics, which are determinants in part of the creatinine production, which is what determines how much creatinine is in the blood before it gets filtered. The equations make us think of GFR and kidney function instead of just the lab value.”
The downsides of using GFRs, he added, include the fact that they are mostly validated in younger patients with kidney disease, they rely on the assumption that demographic characteristics alone can define muscle mass, they were only developed in whites and blacks, and estimated GFR can be interpreted only as “suggested GFR.”
A blood test of kidney function known as cystatin C has been shown to be an alternative, better marker of creatinine, compared with GFR, and is supported by the Kidney Disease: Improving Global Outcomes CKD work group’s 2012 clinical practice guidelines for the evaluation and management of CKD. “Because cystatin C is not related to muscle mass, age, sex, and race, it has major advantages over creatinine,” Dr. Shlipak said. “It is a reliable, standardized, and automated measure that is available for clinical use.”
He and his associates conducted a meta-analysis comparing cystatin C and creatinine in determining prognosis for patients with baseline kidney disease. They included 16 studies involving 90,750 patients and compared associations of estimated GFR (eGFR) as measured with creatinine, cystatin C, and both creatinine and cystatin C with mortality risk; they also determined proportions reclassified by cystatin C in each subgroup of eGFR using creatinine and by the effect on risk associations (N Engl J Med. 2013 Sep 5; 369[10]:932-43).
In the general-population cohorts, the prevalence of an eGFR of less than 60 mL/min per 1.73 m2 of body surface area was higher with the cystatin C–based eGFR than with the creatinine-based eGFR (13.7% vs. 9.7%). Across all eGFR categories, the reclassification of the eGFR to a higher value with the measurement of cystatin C, compared with creatinine, was associated with a reduced risk of all three study outcomes. Reclassification to a lower eGFR was associated with an increased risk.
“When we looked at the threshold for where risk begins, traditionally we’ve said it starts when the GFR declines below 60 mL/min per 1.73 m2,” Dr. Shlipak explained. “That’s exactly what we found with creatinine. But with cystatin C, the threshold of risk was at 88 mL/min per 1.73 m2.
“So, from 88 mL/min per 1.73 m2 downward, every incremental reduction in GFR is associated with higher mortality and cardiovascular risk,” he added. “So cystatin C opens this new window of between 60 and 90 mL/min per 1.73 m2 to start measuring relative declines in kidney function. If you combine creatinine and cystatin C together in an equation, you get a similar estimate. Many advocate that the combined CKD-EPI creatinine-cystatin C equation is the best way to measure GFR.”
Dr. Shlipak reported that he is on the scientific advisory boards of TAI Diagnostics and Cricket Health.
SAN FRANCISCO – Routine lab tests for estimating the average glomerular filtration rate (GFR) are too imprecise, according to Michael G. Shlipak, MD.
“If you study 100 patients, the average GFR based on creatinine is going to be pretty close to estimated GFR,” Dr. Shlipak said at the UCSF Annual Advances in Internal Medicine meeting. “But with individual patients, the average GFR is going to be plus or minus 30%, which is a lot. If the estimated GFR is 70 mL/min per 1.73 m2, the real GFR could be between 50 and 90 mL/min per 1.73 m2; so that’s a wide range.”
“The main appeal of the Cockcroft-Gault equation is that you can almost do it in your head, so that’s a real positive,” said Dr. Shlipak, who is also scientific director of the Kidney Health Research Collaborative at the University of California, San Francisco, and professor of internal medicine, epidemiology, and biostatistics at UCSF Medical Center. “The main disadvantage is that it’s really a terrible equation. The Cockcroft-Gault equation is clearly inadequate, as it is standardized to creatinine clearance and very inaccurate, so it should no longer be used. The MDRD and the CKD-EPI are newer equations that are at least validated to real GFR and not creatinine clearance. In our system, the pharmacy uses the Cockcroft-Gault equation, and the lab gives us the MDRD GFR equation, so it’s quite confusing.”
Dr. Shlipak described using estimated GFR in clinical decision making as “better than using just creatinine, because it integrates demographic characteristics, which are determinants in part of the creatinine production, which is what determines how much creatinine is in the blood before it gets filtered. The equations make us think of GFR and kidney function instead of just the lab value.”
The downsides of using GFRs, he added, include the fact that they are mostly validated in younger patients with kidney disease, they rely on the assumption that demographic characteristics alone can define muscle mass, they were only developed in whites and blacks, and estimated GFR can be interpreted only as “suggested GFR.”
A blood test of kidney function known as cystatin C has been shown to be an alternative, better marker of creatinine, compared with GFR, and is supported by the Kidney Disease: Improving Global Outcomes CKD work group’s 2012 clinical practice guidelines for the evaluation and management of CKD. “Because cystatin C is not related to muscle mass, age, sex, and race, it has major advantages over creatinine,” Dr. Shlipak said. “It is a reliable, standardized, and automated measure that is available for clinical use.”
He and his associates conducted a meta-analysis comparing cystatin C and creatinine in determining prognosis for patients with baseline kidney disease. They included 16 studies involving 90,750 patients and compared associations of estimated GFR (eGFR) as measured with creatinine, cystatin C, and both creatinine and cystatin C with mortality risk; they also determined proportions reclassified by cystatin C in each subgroup of eGFR using creatinine and by the effect on risk associations (N Engl J Med. 2013 Sep 5; 369[10]:932-43).
In the general-population cohorts, the prevalence of an eGFR of less than 60 mL/min per 1.73 m2 of body surface area was higher with the cystatin C–based eGFR than with the creatinine-based eGFR (13.7% vs. 9.7%). Across all eGFR categories, the reclassification of the eGFR to a higher value with the measurement of cystatin C, compared with creatinine, was associated with a reduced risk of all three study outcomes. Reclassification to a lower eGFR was associated with an increased risk.
“When we looked at the threshold for where risk begins, traditionally we’ve said it starts when the GFR declines below 60 mL/min per 1.73 m2,” Dr. Shlipak explained. “That’s exactly what we found with creatinine. But with cystatin C, the threshold of risk was at 88 mL/min per 1.73 m2.
“So, from 88 mL/min per 1.73 m2 downward, every incremental reduction in GFR is associated with higher mortality and cardiovascular risk,” he added. “So cystatin C opens this new window of between 60 and 90 mL/min per 1.73 m2 to start measuring relative declines in kidney function. If you combine creatinine and cystatin C together in an equation, you get a similar estimate. Many advocate that the combined CKD-EPI creatinine-cystatin C equation is the best way to measure GFR.”
Dr. Shlipak reported that he is on the scientific advisory boards of TAI Diagnostics and Cricket Health.
SAN FRANCISCO – Routine lab tests for estimating the average glomerular filtration rate (GFR) are too imprecise, according to Michael G. Shlipak, MD.
“If you study 100 patients, the average GFR based on creatinine is going to be pretty close to estimated GFR,” Dr. Shlipak said at the UCSF Annual Advances in Internal Medicine meeting. “But with individual patients, the average GFR is going to be plus or minus 30%, which is a lot. If the estimated GFR is 70 mL/min per 1.73 m2, the real GFR could be between 50 and 90 mL/min per 1.73 m2; so that’s a wide range.”
“The main appeal of the Cockcroft-Gault equation is that you can almost do it in your head, so that’s a real positive,” said Dr. Shlipak, who is also scientific director of the Kidney Health Research Collaborative at the University of California, San Francisco, and professor of internal medicine, epidemiology, and biostatistics at UCSF Medical Center. “The main disadvantage is that it’s really a terrible equation. The Cockcroft-Gault equation is clearly inadequate, as it is standardized to creatinine clearance and very inaccurate, so it should no longer be used. The MDRD and the CKD-EPI are newer equations that are at least validated to real GFR and not creatinine clearance. In our system, the pharmacy uses the Cockcroft-Gault equation, and the lab gives us the MDRD GFR equation, so it’s quite confusing.”
Dr. Shlipak described using estimated GFR in clinical decision making as “better than using just creatinine, because it integrates demographic characteristics, which are determinants in part of the creatinine production, which is what determines how much creatinine is in the blood before it gets filtered. The equations make us think of GFR and kidney function instead of just the lab value.”
The downsides of using GFRs, he added, include the fact that they are mostly validated in younger patients with kidney disease, they rely on the assumption that demographic characteristics alone can define muscle mass, they were only developed in whites and blacks, and estimated GFR can be interpreted only as “suggested GFR.”
A blood test of kidney function known as cystatin C has been shown to be an alternative, better marker of creatinine, compared with GFR, and is supported by the Kidney Disease: Improving Global Outcomes CKD work group’s 2012 clinical practice guidelines for the evaluation and management of CKD. “Because cystatin C is not related to muscle mass, age, sex, and race, it has major advantages over creatinine,” Dr. Shlipak said. “It is a reliable, standardized, and automated measure that is available for clinical use.”
He and his associates conducted a meta-analysis comparing cystatin C and creatinine in determining prognosis for patients with baseline kidney disease. They included 16 studies involving 90,750 patients and compared associations of estimated GFR (eGFR) as measured with creatinine, cystatin C, and both creatinine and cystatin C with mortality risk; they also determined proportions reclassified by cystatin C in each subgroup of eGFR using creatinine and by the effect on risk associations (N Engl J Med. 2013 Sep 5; 369[10]:932-43).
In the general-population cohorts, the prevalence of an eGFR of less than 60 mL/min per 1.73 m2 of body surface area was higher with the cystatin C–based eGFR than with the creatinine-based eGFR (13.7% vs. 9.7%). Across all eGFR categories, the reclassification of the eGFR to a higher value with the measurement of cystatin C, compared with creatinine, was associated with a reduced risk of all three study outcomes. Reclassification to a lower eGFR was associated with an increased risk.
“When we looked at the threshold for where risk begins, traditionally we’ve said it starts when the GFR declines below 60 mL/min per 1.73 m2,” Dr. Shlipak explained. “That’s exactly what we found with creatinine. But with cystatin C, the threshold of risk was at 88 mL/min per 1.73 m2.
“So, from 88 mL/min per 1.73 m2 downward, every incremental reduction in GFR is associated with higher mortality and cardiovascular risk,” he added. “So cystatin C opens this new window of between 60 and 90 mL/min per 1.73 m2 to start measuring relative declines in kidney function. If you combine creatinine and cystatin C together in an equation, you get a similar estimate. Many advocate that the combined CKD-EPI creatinine-cystatin C equation is the best way to measure GFR.”
Dr. Shlipak reported that he is on the scientific advisory boards of TAI Diagnostics and Cricket Health.
AT THE ANNUAL ADVANCES IN INTERNAL MEDICINE
Role of fidaxomicin for C. difficile infection continues to evolve
SAN FRANCISCO– The role of fidaxomicin for treating mild to moderate Clostridium difficile infection is still finding its way, according to Sarah Doernberg, MD.
For now, fidaxomicin, a narrow spectrum macrocyclic antibiotic, may be appropriate for those at high risk for relapse and/or those requiring concomitant antibiotics – but its high price tag may be prohibitive.
“I think a lot of centers have taken the fidaxomicin data, which were based on patients with initial infection or a single relapse, and extrapolated it to patients with multiple relapses,” Dr. Doernberg, medical director of adult antimicrobial stewardship at UCSF Medical Center, said at the UCSF Annual Advances in Internal Medicine meeting.
In a recent analysis, researchers collected real-world data on implementation of fidaxomicin for CDI patients at seven hospitals in the United Kingdom (Eur J Clin Microbiol Infect Dis. 2016 Feb;35[2]:251-9). In two hospitals where fidaxomicin was used as the first-line treatment for all primary and recurrent episodes, the recurrence rate reduced from 10.6% to 3.1% and from 16.3% to 3.1%, with a significant difference in 28-day mortality, from 18.2% to 3.1%; (P less than .05) and 17.3% to 6.3% (P less than .05). In the remaining five hospitals that used fidaxomicin in selected patients only, the changes in recurrence rates and mortality were less marked.
Other studies have found that fidaxomicin has a similar cure rate, compared with vancomycin (around 88%) but a lower recurrence rate (13%-15%, compared with 25%-27%, respectively; see N Engl J Med. 2011 Feb 3;364[5]:422-31). However, the general cost for a course is significantly more, compared with metronidazole and vancomycin, making fidaxomicin less cost effective as a first-line agent in most cases (Clin Infect Dis. 2013 Aug 15; 57[4]:555-61).
“Our guidelines recommend it in patients who have a very high risk for relapse who would not be candidates for fecal transplant down the line, which generally means immunocompromised patients,” Dr. Doernberg said.
Additional considerations when treating CDI include stopping unnecessary antibiotics, shortening the antibiotic course, narrowing the antibiotic spectrum, and stopping acid-suppressive medication when possible, especially proton pump inhibitors. “Do no use anti-peristaltic agents until acute symptoms of CDI improve,” she said.
Dr. Doernberg disclosed that she is a consultant for Actelion. She has also conducted prior research studies with Cerexa, Cubist, and Merck.
SAN FRANCISCO– The role of fidaxomicin for treating mild to moderate Clostridium difficile infection is still finding its way, according to Sarah Doernberg, MD.
For now, fidaxomicin, a narrow spectrum macrocyclic antibiotic, may be appropriate for those at high risk for relapse and/or those requiring concomitant antibiotics – but its high price tag may be prohibitive.
“I think a lot of centers have taken the fidaxomicin data, which were based on patients with initial infection or a single relapse, and extrapolated it to patients with multiple relapses,” Dr. Doernberg, medical director of adult antimicrobial stewardship at UCSF Medical Center, said at the UCSF Annual Advances in Internal Medicine meeting.
In a recent analysis, researchers collected real-world data on implementation of fidaxomicin for CDI patients at seven hospitals in the United Kingdom (Eur J Clin Microbiol Infect Dis. 2016 Feb;35[2]:251-9). In two hospitals where fidaxomicin was used as the first-line treatment for all primary and recurrent episodes, the recurrence rate reduced from 10.6% to 3.1% and from 16.3% to 3.1%, with a significant difference in 28-day mortality, from 18.2% to 3.1%; (P less than .05) and 17.3% to 6.3% (P less than .05). In the remaining five hospitals that used fidaxomicin in selected patients only, the changes in recurrence rates and mortality were less marked.
Other studies have found that fidaxomicin has a similar cure rate, compared with vancomycin (around 88%) but a lower recurrence rate (13%-15%, compared with 25%-27%, respectively; see N Engl J Med. 2011 Feb 3;364[5]:422-31). However, the general cost for a course is significantly more, compared with metronidazole and vancomycin, making fidaxomicin less cost effective as a first-line agent in most cases (Clin Infect Dis. 2013 Aug 15; 57[4]:555-61).
“Our guidelines recommend it in patients who have a very high risk for relapse who would not be candidates for fecal transplant down the line, which generally means immunocompromised patients,” Dr. Doernberg said.
Additional considerations when treating CDI include stopping unnecessary antibiotics, shortening the antibiotic course, narrowing the antibiotic spectrum, and stopping acid-suppressive medication when possible, especially proton pump inhibitors. “Do no use anti-peristaltic agents until acute symptoms of CDI improve,” she said.
Dr. Doernberg disclosed that she is a consultant for Actelion. She has also conducted prior research studies with Cerexa, Cubist, and Merck.
SAN FRANCISCO– The role of fidaxomicin for treating mild to moderate Clostridium difficile infection is still finding its way, according to Sarah Doernberg, MD.
For now, fidaxomicin, a narrow spectrum macrocyclic antibiotic, may be appropriate for those at high risk for relapse and/or those requiring concomitant antibiotics – but its high price tag may be prohibitive.
“I think a lot of centers have taken the fidaxomicin data, which were based on patients with initial infection or a single relapse, and extrapolated it to patients with multiple relapses,” Dr. Doernberg, medical director of adult antimicrobial stewardship at UCSF Medical Center, said at the UCSF Annual Advances in Internal Medicine meeting.
In a recent analysis, researchers collected real-world data on implementation of fidaxomicin for CDI patients at seven hospitals in the United Kingdom (Eur J Clin Microbiol Infect Dis. 2016 Feb;35[2]:251-9). In two hospitals where fidaxomicin was used as the first-line treatment for all primary and recurrent episodes, the recurrence rate reduced from 10.6% to 3.1% and from 16.3% to 3.1%, with a significant difference in 28-day mortality, from 18.2% to 3.1%; (P less than .05) and 17.3% to 6.3% (P less than .05). In the remaining five hospitals that used fidaxomicin in selected patients only, the changes in recurrence rates and mortality were less marked.
Other studies have found that fidaxomicin has a similar cure rate, compared with vancomycin (around 88%) but a lower recurrence rate (13%-15%, compared with 25%-27%, respectively; see N Engl J Med. 2011 Feb 3;364[5]:422-31). However, the general cost for a course is significantly more, compared with metronidazole and vancomycin, making fidaxomicin less cost effective as a first-line agent in most cases (Clin Infect Dis. 2013 Aug 15; 57[4]:555-61).
“Our guidelines recommend it in patients who have a very high risk for relapse who would not be candidates for fecal transplant down the line, which generally means immunocompromised patients,” Dr. Doernberg said.
Additional considerations when treating CDI include stopping unnecessary antibiotics, shortening the antibiotic course, narrowing the antibiotic spectrum, and stopping acid-suppressive medication when possible, especially proton pump inhibitors. “Do no use anti-peristaltic agents until acute symptoms of CDI improve,” she said.
Dr. Doernberg disclosed that she is a consultant for Actelion. She has also conducted prior research studies with Cerexa, Cubist, and Merck.
AT THE ANNUAL ADVANCES IN INTERNAL MEDICINE
What works and what doesn’t in treating binge eating
SAN FRANCISCO – For patients who meet criteria for binge eating and who express a desire to lose weight, topiramate or lisdexamfetamine are effective treatment options, according to Judith Walsh, MD.
“Binge eating is the most common eating disorder in the United States,” Dr. Walsh said at the UCSF Annual Advances in Internal Medicine meeting. “The lifetime prevalence is 3.5% in women, compared with 2% in men, and 5%-30% of affected women are obese.”
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the condition is characterized by binge eating episodes during which patients consume larger amounts of food than most people would under similar circumstances. “They feel a lack control over eating, [the notion that] ‘I’m eating and I can’t stop,’” said Dr. Walsh of the UCSF division of internal medicine and the Women’s Center for Excellence. Affected patients engage in the behavior of binge eating more than once per week over a period of at least 3 months, and the episodes typically last fewer than 2 hours.
While therapist-led cognitive-behavioral therapy (CBT) is generally considered to be the mainstay of treatment for binge eating disorder, guidelines from the American Psychiatric Association and the National Institute for Health and Care Excellence are conflicting, she said.
A recent meta-analysis funded by the Agency for Healthcare Research and Quality set out to summarize the benefits and harms of psychological and pharmacologic therapies for adults with binge eating disorder (Ann Intern Med. 2016 Sep 20;165[6]:409-20). The researchers evaluated 34 published trials with a low to medium risk of bias, including 25 placebo-controlled trials and 9 waitlist-controlled psychological trials. The majority of trial participants (77%) were women, their mean body mass index was 28.8 kg/m2, and their treatment duration ranged from 6 weeks to 6 months.
The review found that second-generation antidepressants such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline improved abstinence from binge eating (relative risk, 1.67) and depression symptoms (RR, 1.97), but resulted in no weight change. Therapist-led CBT was found to strongly improve abstinence from binge eating (RR, 4.95), but it resulted in no change in depressive symptoms or in weight.
Use of lisdexamfetamine was associated with improved abstinence from binge eating (RR, 2.61) and weight loss of 5.2%-6.3%, while use of topiramate was found in two trials to have a moderate benefit on abstinence from binge eating (by 58%-64% in one trial and by 29%-30% in the other), and weight loss of about 4.9 kg.
“Harms of treatment are generally not reported in the psychological studies, nor in 20 of the 25 pharmacologic studies included in the analysis,” said Dr. Walsh, who was not involved with review. The three trials of lisdexamfetamine found an increased risk of sympathetic nervous system arousal (RR, 4.28), insomnia (RR, 2.8), and GI upset (RR, 2.71).
“So, in adults with binge eating disorder, the primary therapy to increase abstinence is cognitive-behavioral therapy, topiramate, lisdexamfetamine, and second-generation antidepressants,” Dr. Walsh concluded. If reducing weight is a priority, the best available treatment options are topiramate and lisdexamfetamine, she said.
Dr. Walsh reported having no financial disclosures.
SAN FRANCISCO – For patients who meet criteria for binge eating and who express a desire to lose weight, topiramate or lisdexamfetamine are effective treatment options, according to Judith Walsh, MD.
“Binge eating is the most common eating disorder in the United States,” Dr. Walsh said at the UCSF Annual Advances in Internal Medicine meeting. “The lifetime prevalence is 3.5% in women, compared with 2% in men, and 5%-30% of affected women are obese.”
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the condition is characterized by binge eating episodes during which patients consume larger amounts of food than most people would under similar circumstances. “They feel a lack control over eating, [the notion that] ‘I’m eating and I can’t stop,’” said Dr. Walsh of the UCSF division of internal medicine and the Women’s Center for Excellence. Affected patients engage in the behavior of binge eating more than once per week over a period of at least 3 months, and the episodes typically last fewer than 2 hours.
While therapist-led cognitive-behavioral therapy (CBT) is generally considered to be the mainstay of treatment for binge eating disorder, guidelines from the American Psychiatric Association and the National Institute for Health and Care Excellence are conflicting, she said.
A recent meta-analysis funded by the Agency for Healthcare Research and Quality set out to summarize the benefits and harms of psychological and pharmacologic therapies for adults with binge eating disorder (Ann Intern Med. 2016 Sep 20;165[6]:409-20). The researchers evaluated 34 published trials with a low to medium risk of bias, including 25 placebo-controlled trials and 9 waitlist-controlled psychological trials. The majority of trial participants (77%) were women, their mean body mass index was 28.8 kg/m2, and their treatment duration ranged from 6 weeks to 6 months.
The review found that second-generation antidepressants such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline improved abstinence from binge eating (relative risk, 1.67) and depression symptoms (RR, 1.97), but resulted in no weight change. Therapist-led CBT was found to strongly improve abstinence from binge eating (RR, 4.95), but it resulted in no change in depressive symptoms or in weight.
Use of lisdexamfetamine was associated with improved abstinence from binge eating (RR, 2.61) and weight loss of 5.2%-6.3%, while use of topiramate was found in two trials to have a moderate benefit on abstinence from binge eating (by 58%-64% in one trial and by 29%-30% in the other), and weight loss of about 4.9 kg.
“Harms of treatment are generally not reported in the psychological studies, nor in 20 of the 25 pharmacologic studies included in the analysis,” said Dr. Walsh, who was not involved with review. The three trials of lisdexamfetamine found an increased risk of sympathetic nervous system arousal (RR, 4.28), insomnia (RR, 2.8), and GI upset (RR, 2.71).
“So, in adults with binge eating disorder, the primary therapy to increase abstinence is cognitive-behavioral therapy, topiramate, lisdexamfetamine, and second-generation antidepressants,” Dr. Walsh concluded. If reducing weight is a priority, the best available treatment options are topiramate and lisdexamfetamine, she said.
Dr. Walsh reported having no financial disclosures.
SAN FRANCISCO – For patients who meet criteria for binge eating and who express a desire to lose weight, topiramate or lisdexamfetamine are effective treatment options, according to Judith Walsh, MD.
“Binge eating is the most common eating disorder in the United States,” Dr. Walsh said at the UCSF Annual Advances in Internal Medicine meeting. “The lifetime prevalence is 3.5% in women, compared with 2% in men, and 5%-30% of affected women are obese.”
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the condition is characterized by binge eating episodes during which patients consume larger amounts of food than most people would under similar circumstances. “They feel a lack control over eating, [the notion that] ‘I’m eating and I can’t stop,’” said Dr. Walsh of the UCSF division of internal medicine and the Women’s Center for Excellence. Affected patients engage in the behavior of binge eating more than once per week over a period of at least 3 months, and the episodes typically last fewer than 2 hours.
While therapist-led cognitive-behavioral therapy (CBT) is generally considered to be the mainstay of treatment for binge eating disorder, guidelines from the American Psychiatric Association and the National Institute for Health and Care Excellence are conflicting, she said.
A recent meta-analysis funded by the Agency for Healthcare Research and Quality set out to summarize the benefits and harms of psychological and pharmacologic therapies for adults with binge eating disorder (Ann Intern Med. 2016 Sep 20;165[6]:409-20). The researchers evaluated 34 published trials with a low to medium risk of bias, including 25 placebo-controlled trials and 9 waitlist-controlled psychological trials. The majority of trial participants (77%) were women, their mean body mass index was 28.8 kg/m2, and their treatment duration ranged from 6 weeks to 6 months.
The review found that second-generation antidepressants such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline improved abstinence from binge eating (relative risk, 1.67) and depression symptoms (RR, 1.97), but resulted in no weight change. Therapist-led CBT was found to strongly improve abstinence from binge eating (RR, 4.95), but it resulted in no change in depressive symptoms or in weight.
Use of lisdexamfetamine was associated with improved abstinence from binge eating (RR, 2.61) and weight loss of 5.2%-6.3%, while use of topiramate was found in two trials to have a moderate benefit on abstinence from binge eating (by 58%-64% in one trial and by 29%-30% in the other), and weight loss of about 4.9 kg.
“Harms of treatment are generally not reported in the psychological studies, nor in 20 of the 25 pharmacologic studies included in the analysis,” said Dr. Walsh, who was not involved with review. The three trials of lisdexamfetamine found an increased risk of sympathetic nervous system arousal (RR, 4.28), insomnia (RR, 2.8), and GI upset (RR, 2.71).
“So, in adults with binge eating disorder, the primary therapy to increase abstinence is cognitive-behavioral therapy, topiramate, lisdexamfetamine, and second-generation antidepressants,” Dr. Walsh concluded. If reducing weight is a priority, the best available treatment options are topiramate and lisdexamfetamine, she said.
Dr. Walsh reported having no financial disclosures.
EXPERT ANALYSIS AT THE ANNUAL ADVANCES IN INTERNAL MEDICINE
Anabolic agents for osteoporosis have limited role so far
SAN FRANCISCO – Parathyroid hormone and parathyroid hormone–related protein analogs show promise for treating osteoporosis, but, for now, they’re reserved for the most severe cases.
Teriparatide, a parathyroid hormone analog, is the first treatment that stimulates bone formation instead of inhibiting bone resorption, but studies to date are too small to evaluate its effect on hip fractures, Jeffrey A. Tice, MD, said at the UCSF Annual Advances in Internal Medicine meeting.
Abaloparatide, a parathyroid hormone-related protein analog approved in April 2017, requires subcutaneous dosing of 80 mcg daily for up to 2 years and has been found to increase bone density in the spine by 11% and in the hip by 4%, compared with placebo, over 18 months. In women with pre-existing vertebral fractures, the agent was found to reduce the incidence of vertebral fractures by 86% and nonvertebral fragility fractures by 43%, but data are not adequate to evaluate its effect on hip fractures. Adverse reactions include hypercalciuria, nausea, hypercalcemia, orthostatic hypotension, tachycardia, and injection site reactions.
Studies to date have shown that combining either teriparatide or abaloparatide with an antiresorptive drug is less effective than either agent alone. However, both agents must be followed by an antiresorptive agent. “These drugs are expensive,” Dr. Tice said. “Right now, they’re reserved for patients with severe osteoporosis.”
The lifetime risk for osteoporotic fractures is 50% in women and 20% in men, and they cause significant morbidity and mortality. Among U.S. hospitalizations for women 55 years and older between 2000 and 2012, Dr. Tice noted, 4.9 million were for osteoporotic fractures, 3 million were for stroke, and 2.9 million were for myocardial infarction.
“Osteoporosis is a very common condition, but it’s under-recognized, in part because it’s a silent disease,” he said. “Only 20%-30% of patients with bone mineral densities less than –2.5 are treated in this country. And, 12 months after hip fracture, only 2% had a dual-energy x-ray absorptiometry [DXA] test, and only 15% were treated with an appropriate drug. We should be asking about fracture history, note vertebral fractures, treat those patients, and we should remember to use chart reminders for DXA.”
Clinical guidelines from the American College of Physicians and other groups recommend alendronate, risedronate, zoledronic acid, or denosumab as first-line therapy for women with osteoporosis. “There are no head to head trials to indicate which agent is best,” Dr. Tice said. “They reduce the fracture risk by 30%-50%, primarily in patients with an existing vertebral fracture or a T score below –2.5.” The use of hormone therapy and raloxifene are generally not recommended.
In a review published in the New England Journal of Medicine, researchers Dennis M. Black, MD, and Clifford J. Rosen, MD, estimated the number of patients needed to treat for 3 years to prevent various fractures (N Engl J Med. 2016 Jan 21;374[3]:254-62). They found that, for nonvertebral fractures, including hip, 35 patients need to be treated for 3 years to prevent one of those fractures, 90 patients for 3 years to prevent one hip fracture, and 14 patients for 3 years to prevent one vertebral fracture.
In the FIT trial, 20% of women taking alendronate lost BMD during the first year (JAMA. 1998 Dec 23-30;280[24]:2077-82). However, those same patients had a 50% fracture reduction, and 92% regained the lost bone mineral density (BMD) by the next measurement. “Using DXA to measure BMD after 1 year of therapy does not accurately predict what will happen over time or reflect fracture reduction,” Dr. Tice said. “Effective treatment for osteoporosis should not be changed because of loss of BMD during the first year of use.”
A rare but potential harm from treatment with bisphosphonates includes osteonecrosis of the jaw, which is believed to affect only 1 in 10,000 patients who are treated for 10 years. Most of these cases (94%) were caused by IV bisphosphonates. Only 4% of cases were being treated for osteoporosis, and 60% were caused by tooth extraction. Because of this, a dental exam is recommended before starting patients on bisphosphonate therapy, but this small risk of osteonecrosis of the jaw “is not a reason to stop bisphosphonate therapy,” Dr. Tice said.
Other concerns include an increased risk for atrial fibrillation that has been observed in randomized, controlled trials of zoledronate and alendronate. “There has been no association in other trials,” Dr. Tice said. “This is likely a chance finding, likely spurious.”
Reports of an increased risk of esophageal cancer from bisphosphonate use have also been suggested, but these come from case series and from two conflicting cohorts of data. “This is most likely not a real finding but is a concern because of clinical reports of esophagitis associated with oral bisphosphonates,” he said.
Another concern from long-term bisphosphonate use is the development of atypical femoral fractures, a subtrochanteric fracture with atypical features. “These are transverse fractures of the femur and are likely a real effect of bisphosphonates,” Dr. Tice said. “They are characterized by transverse fractures, cortical thickening, and the 10-year risk is about 1:200. It’s similar to a stress fracture, and it’s often preceded by pain.”
To bring perspective on the risk of developing an atypical femoral fracture, Dr. Tice offered a comparison. If 1,000 women are treated for 3 years with zoledronic acid, it will prevent 71 vertebral fractures, 11 hip fractures, and 18 other fractures. “So, the best estimate is that you would cause 0.1 atypical femoral fractures,” he said. “That really means that, for every one atypical femoral fracture caused, you’ve prevented 110 hip fractures. So, yes, there’s a risk of harm – but there is so much more benefit.”
Dr. Tice reported having no relevant financial disclosures.
SAN FRANCISCO – Parathyroid hormone and parathyroid hormone–related protein analogs show promise for treating osteoporosis, but, for now, they’re reserved for the most severe cases.
Teriparatide, a parathyroid hormone analog, is the first treatment that stimulates bone formation instead of inhibiting bone resorption, but studies to date are too small to evaluate its effect on hip fractures, Jeffrey A. Tice, MD, said at the UCSF Annual Advances in Internal Medicine meeting.
Abaloparatide, a parathyroid hormone-related protein analog approved in April 2017, requires subcutaneous dosing of 80 mcg daily for up to 2 years and has been found to increase bone density in the spine by 11% and in the hip by 4%, compared with placebo, over 18 months. In women with pre-existing vertebral fractures, the agent was found to reduce the incidence of vertebral fractures by 86% and nonvertebral fragility fractures by 43%, but data are not adequate to evaluate its effect on hip fractures. Adverse reactions include hypercalciuria, nausea, hypercalcemia, orthostatic hypotension, tachycardia, and injection site reactions.
Studies to date have shown that combining either teriparatide or abaloparatide with an antiresorptive drug is less effective than either agent alone. However, both agents must be followed by an antiresorptive agent. “These drugs are expensive,” Dr. Tice said. “Right now, they’re reserved for patients with severe osteoporosis.”
The lifetime risk for osteoporotic fractures is 50% in women and 20% in men, and they cause significant morbidity and mortality. Among U.S. hospitalizations for women 55 years and older between 2000 and 2012, Dr. Tice noted, 4.9 million were for osteoporotic fractures, 3 million were for stroke, and 2.9 million were for myocardial infarction.
“Osteoporosis is a very common condition, but it’s under-recognized, in part because it’s a silent disease,” he said. “Only 20%-30% of patients with bone mineral densities less than –2.5 are treated in this country. And, 12 months after hip fracture, only 2% had a dual-energy x-ray absorptiometry [DXA] test, and only 15% were treated with an appropriate drug. We should be asking about fracture history, note vertebral fractures, treat those patients, and we should remember to use chart reminders for DXA.”
Clinical guidelines from the American College of Physicians and other groups recommend alendronate, risedronate, zoledronic acid, or denosumab as first-line therapy for women with osteoporosis. “There are no head to head trials to indicate which agent is best,” Dr. Tice said. “They reduce the fracture risk by 30%-50%, primarily in patients with an existing vertebral fracture or a T score below –2.5.” The use of hormone therapy and raloxifene are generally not recommended.
In a review published in the New England Journal of Medicine, researchers Dennis M. Black, MD, and Clifford J. Rosen, MD, estimated the number of patients needed to treat for 3 years to prevent various fractures (N Engl J Med. 2016 Jan 21;374[3]:254-62). They found that, for nonvertebral fractures, including hip, 35 patients need to be treated for 3 years to prevent one of those fractures, 90 patients for 3 years to prevent one hip fracture, and 14 patients for 3 years to prevent one vertebral fracture.
In the FIT trial, 20% of women taking alendronate lost BMD during the first year (JAMA. 1998 Dec 23-30;280[24]:2077-82). However, those same patients had a 50% fracture reduction, and 92% regained the lost bone mineral density (BMD) by the next measurement. “Using DXA to measure BMD after 1 year of therapy does not accurately predict what will happen over time or reflect fracture reduction,” Dr. Tice said. “Effective treatment for osteoporosis should not be changed because of loss of BMD during the first year of use.”
A rare but potential harm from treatment with bisphosphonates includes osteonecrosis of the jaw, which is believed to affect only 1 in 10,000 patients who are treated for 10 years. Most of these cases (94%) were caused by IV bisphosphonates. Only 4% of cases were being treated for osteoporosis, and 60% were caused by tooth extraction. Because of this, a dental exam is recommended before starting patients on bisphosphonate therapy, but this small risk of osteonecrosis of the jaw “is not a reason to stop bisphosphonate therapy,” Dr. Tice said.
Other concerns include an increased risk for atrial fibrillation that has been observed in randomized, controlled trials of zoledronate and alendronate. “There has been no association in other trials,” Dr. Tice said. “This is likely a chance finding, likely spurious.”
Reports of an increased risk of esophageal cancer from bisphosphonate use have also been suggested, but these come from case series and from two conflicting cohorts of data. “This is most likely not a real finding but is a concern because of clinical reports of esophagitis associated with oral bisphosphonates,” he said.
Another concern from long-term bisphosphonate use is the development of atypical femoral fractures, a subtrochanteric fracture with atypical features. “These are transverse fractures of the femur and are likely a real effect of bisphosphonates,” Dr. Tice said. “They are characterized by transverse fractures, cortical thickening, and the 10-year risk is about 1:200. It’s similar to a stress fracture, and it’s often preceded by pain.”
To bring perspective on the risk of developing an atypical femoral fracture, Dr. Tice offered a comparison. If 1,000 women are treated for 3 years with zoledronic acid, it will prevent 71 vertebral fractures, 11 hip fractures, and 18 other fractures. “So, the best estimate is that you would cause 0.1 atypical femoral fractures,” he said. “That really means that, for every one atypical femoral fracture caused, you’ve prevented 110 hip fractures. So, yes, there’s a risk of harm – but there is so much more benefit.”
Dr. Tice reported having no relevant financial disclosures.
SAN FRANCISCO – Parathyroid hormone and parathyroid hormone–related protein analogs show promise for treating osteoporosis, but, for now, they’re reserved for the most severe cases.
Teriparatide, a parathyroid hormone analog, is the first treatment that stimulates bone formation instead of inhibiting bone resorption, but studies to date are too small to evaluate its effect on hip fractures, Jeffrey A. Tice, MD, said at the UCSF Annual Advances in Internal Medicine meeting.
Abaloparatide, a parathyroid hormone-related protein analog approved in April 2017, requires subcutaneous dosing of 80 mcg daily for up to 2 years and has been found to increase bone density in the spine by 11% and in the hip by 4%, compared with placebo, over 18 months. In women with pre-existing vertebral fractures, the agent was found to reduce the incidence of vertebral fractures by 86% and nonvertebral fragility fractures by 43%, but data are not adequate to evaluate its effect on hip fractures. Adverse reactions include hypercalciuria, nausea, hypercalcemia, orthostatic hypotension, tachycardia, and injection site reactions.
Studies to date have shown that combining either teriparatide or abaloparatide with an antiresorptive drug is less effective than either agent alone. However, both agents must be followed by an antiresorptive agent. “These drugs are expensive,” Dr. Tice said. “Right now, they’re reserved for patients with severe osteoporosis.”
The lifetime risk for osteoporotic fractures is 50% in women and 20% in men, and they cause significant morbidity and mortality. Among U.S. hospitalizations for women 55 years and older between 2000 and 2012, Dr. Tice noted, 4.9 million were for osteoporotic fractures, 3 million were for stroke, and 2.9 million were for myocardial infarction.
“Osteoporosis is a very common condition, but it’s under-recognized, in part because it’s a silent disease,” he said. “Only 20%-30% of patients with bone mineral densities less than –2.5 are treated in this country. And, 12 months after hip fracture, only 2% had a dual-energy x-ray absorptiometry [DXA] test, and only 15% were treated with an appropriate drug. We should be asking about fracture history, note vertebral fractures, treat those patients, and we should remember to use chart reminders for DXA.”
Clinical guidelines from the American College of Physicians and other groups recommend alendronate, risedronate, zoledronic acid, or denosumab as first-line therapy for women with osteoporosis. “There are no head to head trials to indicate which agent is best,” Dr. Tice said. “They reduce the fracture risk by 30%-50%, primarily in patients with an existing vertebral fracture or a T score below –2.5.” The use of hormone therapy and raloxifene are generally not recommended.
In a review published in the New England Journal of Medicine, researchers Dennis M. Black, MD, and Clifford J. Rosen, MD, estimated the number of patients needed to treat for 3 years to prevent various fractures (N Engl J Med. 2016 Jan 21;374[3]:254-62). They found that, for nonvertebral fractures, including hip, 35 patients need to be treated for 3 years to prevent one of those fractures, 90 patients for 3 years to prevent one hip fracture, and 14 patients for 3 years to prevent one vertebral fracture.
In the FIT trial, 20% of women taking alendronate lost BMD during the first year (JAMA. 1998 Dec 23-30;280[24]:2077-82). However, those same patients had a 50% fracture reduction, and 92% regained the lost bone mineral density (BMD) by the next measurement. “Using DXA to measure BMD after 1 year of therapy does not accurately predict what will happen over time or reflect fracture reduction,” Dr. Tice said. “Effective treatment for osteoporosis should not be changed because of loss of BMD during the first year of use.”
A rare but potential harm from treatment with bisphosphonates includes osteonecrosis of the jaw, which is believed to affect only 1 in 10,000 patients who are treated for 10 years. Most of these cases (94%) were caused by IV bisphosphonates. Only 4% of cases were being treated for osteoporosis, and 60% were caused by tooth extraction. Because of this, a dental exam is recommended before starting patients on bisphosphonate therapy, but this small risk of osteonecrosis of the jaw “is not a reason to stop bisphosphonate therapy,” Dr. Tice said.
Other concerns include an increased risk for atrial fibrillation that has been observed in randomized, controlled trials of zoledronate and alendronate. “There has been no association in other trials,” Dr. Tice said. “This is likely a chance finding, likely spurious.”
Reports of an increased risk of esophageal cancer from bisphosphonate use have also been suggested, but these come from case series and from two conflicting cohorts of data. “This is most likely not a real finding but is a concern because of clinical reports of esophagitis associated with oral bisphosphonates,” he said.
Another concern from long-term bisphosphonate use is the development of atypical femoral fractures, a subtrochanteric fracture with atypical features. “These are transverse fractures of the femur and are likely a real effect of bisphosphonates,” Dr. Tice said. “They are characterized by transverse fractures, cortical thickening, and the 10-year risk is about 1:200. It’s similar to a stress fracture, and it’s often preceded by pain.”
To bring perspective on the risk of developing an atypical femoral fracture, Dr. Tice offered a comparison. If 1,000 women are treated for 3 years with zoledronic acid, it will prevent 71 vertebral fractures, 11 hip fractures, and 18 other fractures. “So, the best estimate is that you would cause 0.1 atypical femoral fractures,” he said. “That really means that, for every one atypical femoral fracture caused, you’ve prevented 110 hip fractures. So, yes, there’s a risk of harm – but there is so much more benefit.”
Dr. Tice reported having no relevant financial disclosures.
EXPERT ANALYSIS FROM THE ANNUAL ADVANCES IN INTERNAL MEDICINE
How primary care physicians can hit the mark on contraceptive counseling
SAN FRANCISCO – When it comes to counseling women about contraceptive care and family planning, many primary care physicians fall short, according to Christine Dehlendorf, MD.
“Providing contraceptive care and family planning care is part of what we do as preventive care for women of reproductive age, but we don’t always do it as often as we should,” Dr. Dehlendorf said at the UCSF Annual Advances in Internal Medicine meeting. “We don’t often take the initiative of making sure that women’s contraceptive needs are being met at all visits when we engage with them.”
“Many of you might think that’s okay, because we’re only talking about it when women come in for family planning visits,” said Dr. Dehlendorf of the departments of family and community medicine and obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. “In fact, this is something that is an ongoing need for women. We should be using every opportunity to make sure we’re helping them, even if it’s just by initiating the conversation and providing referrals as appropriate.”
Some might think that the best approach to contraceptive decision making involves recommending the most highly effective methods, such as long-acting reversible contraceptives, which have a risk of failure that’s 20 times lower than that of short-acting hormonal methods. Examples of counseling approaches used in that context include tiered effectiveness, in which the clinician presents methods in order of effectiveness, and motivational interviewing, a counseling approach developed for use in people with addictions.
However, Dr. Dehlendorf said she prefers to view contraceptive choice as a decision driven by women’s values and preferences.
“We know that effectiveness is very important to women, but we also know that things like side-effect profile and control over the [contraceptive] method are important as well,” she explained. “These strong features reflect women’s different assessments of the desirability of different outcomes associated with contraceptive use.
“For example, some women think that the possibility of amenorrhea with progestin IUDs or Depo-Provera is a great thing, and other people think it would be horrible,” Dr. Dehlendorf noted. “It has nothing to do with safety or effectiveness; this has to do with how women view that characteristic in the context of their own values and preferences.”
The differential value that women may place on contraceptive effectiveness also relates to different perceptions they have of the possibility of an unplanned pregnancy in their lives, and how important that is to avoid.
“In general, in the public health and clinical dialogue, the idea is that an unplanned pregnancy is an inherently bad pregnancy,” Dr. Dehlendorf said. “The conventional dialogue involves the notion of intentions and plans: Are they intending or planning to get pregnant? Intentions being timing-based ideas of when to get pregnant, and plans being concrete steps they take to act on those intentions.”
However, an emerging body of literature has shown that there are other dimensions of how women think about the possibility of pregnancy in their lives that are distinct from intentions and plans, she said, such as desire, which is how strongly they intend or don’t intend to have a pregnancy, and feelings, their emotional orientation around the potential for a pregnancy in their life.
“You could argue that this is overcomplicating things, but that is not true,” Dr. Dehlendorf said. “Plans, intentions, desires, and feelings are all different concepts, and some of them are more or less relevant to individual women, and they don’t always align with each other. That’s very much in conflict with how we conventionally talk about pregnancy in women’s lives.”
Examples from qualitative research have fleshed this out.
In one recently published study, researchers led by Jenny A. Higgins, PhD, of the department of gender and women’s studies at the University of Wisconsin–Madison, asked women about their views on IUDs. One woman said, “I guess one of the reasons that I haven’t gotten an IUD yet is like, I don’t know, having one kid already and being in a long-term committed relationship, it takes the element of surprise out of when we would have our next kid, which I kind of want. I’m in that weird position. I just don’t want to put too much thought and planning into when I have my next kid.”
Other women view an unplanned pregnancy as emotionally welcome.
In a longitudinal study that measured prospective pregnancy intentions and feelings among 403 women in Austin, Tex., one woman said, “Another pregnancy is definitely not the right path for me, and I’m being very careful with birth control. But if I somehow ended up pregnant, would I embrace it and think it’s for the best? Absolutely.”
Another study participant said, “I don’t want more kids and was hoping to get my tubes tied. We can’t afford another one. But if it happened, I’d still be happy. I’d be really excited. We’d rise to the occasion. Nothing would really change” (Soc Sci Med. 2015 May;132:149-155).
According to Dr. Dehlendorf, the lesson from such studies is that women are going to assess the importance of the efficacy of their contraceptive method differently, depending on how important it is for them to prevent an unintended pregnancy.
“They’re not going to make a decision about effectiveness the way we as clinicians might think that they should,” she said. “So, assuming that highly effective methods are the best methods for all women because of their effectiveness ignores the variability in preferences, and it also doesn’t take into account women’s strong feelings about other aspects of contraceptive use, such as bleeding profiles and control over their methods.”
Shared decision making may be the best way to help women make a choice based on their preferences. In a study that Dr. Dehlendorf and her associates conducted in 348 women who were seen for contraceptive care in the San Francisco Bay area, two habits were associated with contraceptive continuation: investing in the beginning, and eliciting the patient’s perspective (Am J Obstet Gynecol. 2016 Jul;215[1]:78.e1-9). “Investing in the beginning consists of greeting the patient warmly, making small talk, and treating the patient as a person,” she said. “That was the most highly influential aspect of the interaction. Building rapport and decision support helps women choose a method that’s a good fit for them.
“We also know that women like this method of counseling, but this approach might not be for everyone,” Dr. Dehlendorf cautioned. “Some women don’t want your suggestions, even if it’s grounded in their preferences. They just want to get the method that they came in for. The right thing is to acknowledge that, but you can also ask women if they want to hear about other methods, because some women might not know about all of their options.”
Dr. Dehlendorf reported having no relevant financial disclosures.
SAN FRANCISCO – When it comes to counseling women about contraceptive care and family planning, many primary care physicians fall short, according to Christine Dehlendorf, MD.
“Providing contraceptive care and family planning care is part of what we do as preventive care for women of reproductive age, but we don’t always do it as often as we should,” Dr. Dehlendorf said at the UCSF Annual Advances in Internal Medicine meeting. “We don’t often take the initiative of making sure that women’s contraceptive needs are being met at all visits when we engage with them.”
“Many of you might think that’s okay, because we’re only talking about it when women come in for family planning visits,” said Dr. Dehlendorf of the departments of family and community medicine and obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. “In fact, this is something that is an ongoing need for women. We should be using every opportunity to make sure we’re helping them, even if it’s just by initiating the conversation and providing referrals as appropriate.”
Some might think that the best approach to contraceptive decision making involves recommending the most highly effective methods, such as long-acting reversible contraceptives, which have a risk of failure that’s 20 times lower than that of short-acting hormonal methods. Examples of counseling approaches used in that context include tiered effectiveness, in which the clinician presents methods in order of effectiveness, and motivational interviewing, a counseling approach developed for use in people with addictions.
However, Dr. Dehlendorf said she prefers to view contraceptive choice as a decision driven by women’s values and preferences.
“We know that effectiveness is very important to women, but we also know that things like side-effect profile and control over the [contraceptive] method are important as well,” she explained. “These strong features reflect women’s different assessments of the desirability of different outcomes associated with contraceptive use.
“For example, some women think that the possibility of amenorrhea with progestin IUDs or Depo-Provera is a great thing, and other people think it would be horrible,” Dr. Dehlendorf noted. “It has nothing to do with safety or effectiveness; this has to do with how women view that characteristic in the context of their own values and preferences.”
The differential value that women may place on contraceptive effectiveness also relates to different perceptions they have of the possibility of an unplanned pregnancy in their lives, and how important that is to avoid.
“In general, in the public health and clinical dialogue, the idea is that an unplanned pregnancy is an inherently bad pregnancy,” Dr. Dehlendorf said. “The conventional dialogue involves the notion of intentions and plans: Are they intending or planning to get pregnant? Intentions being timing-based ideas of when to get pregnant, and plans being concrete steps they take to act on those intentions.”
However, an emerging body of literature has shown that there are other dimensions of how women think about the possibility of pregnancy in their lives that are distinct from intentions and plans, she said, such as desire, which is how strongly they intend or don’t intend to have a pregnancy, and feelings, their emotional orientation around the potential for a pregnancy in their life.
“You could argue that this is overcomplicating things, but that is not true,” Dr. Dehlendorf said. “Plans, intentions, desires, and feelings are all different concepts, and some of them are more or less relevant to individual women, and they don’t always align with each other. That’s very much in conflict with how we conventionally talk about pregnancy in women’s lives.”
Examples from qualitative research have fleshed this out.
In one recently published study, researchers led by Jenny A. Higgins, PhD, of the department of gender and women’s studies at the University of Wisconsin–Madison, asked women about their views on IUDs. One woman said, “I guess one of the reasons that I haven’t gotten an IUD yet is like, I don’t know, having one kid already and being in a long-term committed relationship, it takes the element of surprise out of when we would have our next kid, which I kind of want. I’m in that weird position. I just don’t want to put too much thought and planning into when I have my next kid.”
Other women view an unplanned pregnancy as emotionally welcome.
In a longitudinal study that measured prospective pregnancy intentions and feelings among 403 women in Austin, Tex., one woman said, “Another pregnancy is definitely not the right path for me, and I’m being very careful with birth control. But if I somehow ended up pregnant, would I embrace it and think it’s for the best? Absolutely.”
Another study participant said, “I don’t want more kids and was hoping to get my tubes tied. We can’t afford another one. But if it happened, I’d still be happy. I’d be really excited. We’d rise to the occasion. Nothing would really change” (Soc Sci Med. 2015 May;132:149-155).
According to Dr. Dehlendorf, the lesson from such studies is that women are going to assess the importance of the efficacy of their contraceptive method differently, depending on how important it is for them to prevent an unintended pregnancy.
“They’re not going to make a decision about effectiveness the way we as clinicians might think that they should,” she said. “So, assuming that highly effective methods are the best methods for all women because of their effectiveness ignores the variability in preferences, and it also doesn’t take into account women’s strong feelings about other aspects of contraceptive use, such as bleeding profiles and control over their methods.”
Shared decision making may be the best way to help women make a choice based on their preferences. In a study that Dr. Dehlendorf and her associates conducted in 348 women who were seen for contraceptive care in the San Francisco Bay area, two habits were associated with contraceptive continuation: investing in the beginning, and eliciting the patient’s perspective (Am J Obstet Gynecol. 2016 Jul;215[1]:78.e1-9). “Investing in the beginning consists of greeting the patient warmly, making small talk, and treating the patient as a person,” she said. “That was the most highly influential aspect of the interaction. Building rapport and decision support helps women choose a method that’s a good fit for them.
“We also know that women like this method of counseling, but this approach might not be for everyone,” Dr. Dehlendorf cautioned. “Some women don’t want your suggestions, even if it’s grounded in their preferences. They just want to get the method that they came in for. The right thing is to acknowledge that, but you can also ask women if they want to hear about other methods, because some women might not know about all of their options.”
Dr. Dehlendorf reported having no relevant financial disclosures.
SAN FRANCISCO – When it comes to counseling women about contraceptive care and family planning, many primary care physicians fall short, according to Christine Dehlendorf, MD.
“Providing contraceptive care and family planning care is part of what we do as preventive care for women of reproductive age, but we don’t always do it as often as we should,” Dr. Dehlendorf said at the UCSF Annual Advances in Internal Medicine meeting. “We don’t often take the initiative of making sure that women’s contraceptive needs are being met at all visits when we engage with them.”
“Many of you might think that’s okay, because we’re only talking about it when women come in for family planning visits,” said Dr. Dehlendorf of the departments of family and community medicine and obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. “In fact, this is something that is an ongoing need for women. We should be using every opportunity to make sure we’re helping them, even if it’s just by initiating the conversation and providing referrals as appropriate.”
Some might think that the best approach to contraceptive decision making involves recommending the most highly effective methods, such as long-acting reversible contraceptives, which have a risk of failure that’s 20 times lower than that of short-acting hormonal methods. Examples of counseling approaches used in that context include tiered effectiveness, in which the clinician presents methods in order of effectiveness, and motivational interviewing, a counseling approach developed for use in people with addictions.
However, Dr. Dehlendorf said she prefers to view contraceptive choice as a decision driven by women’s values and preferences.
“We know that effectiveness is very important to women, but we also know that things like side-effect profile and control over the [contraceptive] method are important as well,” she explained. “These strong features reflect women’s different assessments of the desirability of different outcomes associated with contraceptive use.
“For example, some women think that the possibility of amenorrhea with progestin IUDs or Depo-Provera is a great thing, and other people think it would be horrible,” Dr. Dehlendorf noted. “It has nothing to do with safety or effectiveness; this has to do with how women view that characteristic in the context of their own values and preferences.”
The differential value that women may place on contraceptive effectiveness also relates to different perceptions they have of the possibility of an unplanned pregnancy in their lives, and how important that is to avoid.
“In general, in the public health and clinical dialogue, the idea is that an unplanned pregnancy is an inherently bad pregnancy,” Dr. Dehlendorf said. “The conventional dialogue involves the notion of intentions and plans: Are they intending or planning to get pregnant? Intentions being timing-based ideas of when to get pregnant, and plans being concrete steps they take to act on those intentions.”
However, an emerging body of literature has shown that there are other dimensions of how women think about the possibility of pregnancy in their lives that are distinct from intentions and plans, she said, such as desire, which is how strongly they intend or don’t intend to have a pregnancy, and feelings, their emotional orientation around the potential for a pregnancy in their life.
“You could argue that this is overcomplicating things, but that is not true,” Dr. Dehlendorf said. “Plans, intentions, desires, and feelings are all different concepts, and some of them are more or less relevant to individual women, and they don’t always align with each other. That’s very much in conflict with how we conventionally talk about pregnancy in women’s lives.”
Examples from qualitative research have fleshed this out.
In one recently published study, researchers led by Jenny A. Higgins, PhD, of the department of gender and women’s studies at the University of Wisconsin–Madison, asked women about their views on IUDs. One woman said, “I guess one of the reasons that I haven’t gotten an IUD yet is like, I don’t know, having one kid already and being in a long-term committed relationship, it takes the element of surprise out of when we would have our next kid, which I kind of want. I’m in that weird position. I just don’t want to put too much thought and planning into when I have my next kid.”
Other women view an unplanned pregnancy as emotionally welcome.
In a longitudinal study that measured prospective pregnancy intentions and feelings among 403 women in Austin, Tex., one woman said, “Another pregnancy is definitely not the right path for me, and I’m being very careful with birth control. But if I somehow ended up pregnant, would I embrace it and think it’s for the best? Absolutely.”
Another study participant said, “I don’t want more kids and was hoping to get my tubes tied. We can’t afford another one. But if it happened, I’d still be happy. I’d be really excited. We’d rise to the occasion. Nothing would really change” (Soc Sci Med. 2015 May;132:149-155).
According to Dr. Dehlendorf, the lesson from such studies is that women are going to assess the importance of the efficacy of their contraceptive method differently, depending on how important it is for them to prevent an unintended pregnancy.
“They’re not going to make a decision about effectiveness the way we as clinicians might think that they should,” she said. “So, assuming that highly effective methods are the best methods for all women because of their effectiveness ignores the variability in preferences, and it also doesn’t take into account women’s strong feelings about other aspects of contraceptive use, such as bleeding profiles and control over their methods.”
Shared decision making may be the best way to help women make a choice based on their preferences. In a study that Dr. Dehlendorf and her associates conducted in 348 women who were seen for contraceptive care in the San Francisco Bay area, two habits were associated with contraceptive continuation: investing in the beginning, and eliciting the patient’s perspective (Am J Obstet Gynecol. 2016 Jul;215[1]:78.e1-9). “Investing in the beginning consists of greeting the patient warmly, making small talk, and treating the patient as a person,” she said. “That was the most highly influential aspect of the interaction. Building rapport and decision support helps women choose a method that’s a good fit for them.
“We also know that women like this method of counseling, but this approach might not be for everyone,” Dr. Dehlendorf cautioned. “Some women don’t want your suggestions, even if it’s grounded in their preferences. They just want to get the method that they came in for. The right thing is to acknowledge that, but you can also ask women if they want to hear about other methods, because some women might not know about all of their options.”
Dr. Dehlendorf reported having no relevant financial disclosures.
AT THE ANNUAL ADVANCES IN INTERNAL MEDICINE
Optimal age for cardiovascular disease screening remains elusive
SAN FRANCISCO – In the United States, deaths from cardiovascular disease fell by about 50% in men and women between 1980 and 2000, and fell an additional 31% between 2000 and 2010, according to Robert Baron, MD.
That’s the good news, driven largely by the introduction of statin therapy and by risk-factor modifications. The not-so-great news? The optimal screening age for CVD risk remains elusive.
“We’ve been arguing about this for at least 30 years,” he said at the UCSF Annual Advances in Internal Medicine.
The 2013 American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk recommends screening at age 21 years to identify those with an LDL cholesterol level greater than 190 mg/dL, while a more recent draft recommendation statement from the United States Preventive Services Task Force (USPSTF) recommends screening at age 35 in men and 45 in women for most cases, or at age 20 in people deemed to be at increased risk. Both sets of guidelines recommend the use of statins in patients with atherosclerotic cardiovascular disease, and LDL of 190 mg/dL or greater, and/or diabetes.
“In essence, the USPSTF guidelines are saying definitely use statins for primary prevention in high-risk people; they’re just creating a little more gray area as to what exactly constitutes high risk,” said Dr. Baron, an internist who is associate dean at UCSF Medical Center, San Francisco. “The question is, how do you draw the line? I would argue that depends on the patient preference.”
In a recently published analysis, researchers set out to determine how the USPSTF guidelines compare with the ACC/AHA guidelines in terms of the proportion of U.S. adults potentially treated (JAMA. 2017 Apr 18; 317[15]:1563-7). After using estimates based on data from 3,416 participants in the 2009-2014 National Health and Nutrition Examination Survey, the researchers found that USPSTF recommendations would be associated with statin initiation in 16% of U.S. adults aged 40-75 years without prior CVD, compared with 24% according to the ACC/AHA guidelines.
Among those adults for whom therapy would no longer be recommended under the USPSTF recommendations, 55% are aged 40-59 years with a mean 30-year cardiovascular risk exceeding 30%, and 28% have diabetes. According to Dr. Baron, the comparison “reinforces the primary prevention message. It gives the patient a bit more flexibility.”
After starting patients on a statin, the best available evidence recommends monitoring adherence but not treating to a specific LDL goal, he said. Statins should not be used in patients older than age 75 unless they have existing ASCVD. The addition of other lipid-modifying drugs is generally not recommended, but it may be needed in patients who demonstrate intolerance to statins. Patients should also avoid using NSAIDS, which raise CVD risk, and instead use medications that lower it, such as aspirin, he said.
Dr. Baron reported having no relevant financial disclosures.
SAN FRANCISCO – In the United States, deaths from cardiovascular disease fell by about 50% in men and women between 1980 and 2000, and fell an additional 31% between 2000 and 2010, according to Robert Baron, MD.
That’s the good news, driven largely by the introduction of statin therapy and by risk-factor modifications. The not-so-great news? The optimal screening age for CVD risk remains elusive.
“We’ve been arguing about this for at least 30 years,” he said at the UCSF Annual Advances in Internal Medicine.
The 2013 American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk recommends screening at age 21 years to identify those with an LDL cholesterol level greater than 190 mg/dL, while a more recent draft recommendation statement from the United States Preventive Services Task Force (USPSTF) recommends screening at age 35 in men and 45 in women for most cases, or at age 20 in people deemed to be at increased risk. Both sets of guidelines recommend the use of statins in patients with atherosclerotic cardiovascular disease, and LDL of 190 mg/dL or greater, and/or diabetes.
“In essence, the USPSTF guidelines are saying definitely use statins for primary prevention in high-risk people; they’re just creating a little more gray area as to what exactly constitutes high risk,” said Dr. Baron, an internist who is associate dean at UCSF Medical Center, San Francisco. “The question is, how do you draw the line? I would argue that depends on the patient preference.”
In a recently published analysis, researchers set out to determine how the USPSTF guidelines compare with the ACC/AHA guidelines in terms of the proportion of U.S. adults potentially treated (JAMA. 2017 Apr 18; 317[15]:1563-7). After using estimates based on data from 3,416 participants in the 2009-2014 National Health and Nutrition Examination Survey, the researchers found that USPSTF recommendations would be associated with statin initiation in 16% of U.S. adults aged 40-75 years without prior CVD, compared with 24% according to the ACC/AHA guidelines.
Among those adults for whom therapy would no longer be recommended under the USPSTF recommendations, 55% are aged 40-59 years with a mean 30-year cardiovascular risk exceeding 30%, and 28% have diabetes. According to Dr. Baron, the comparison “reinforces the primary prevention message. It gives the patient a bit more flexibility.”
After starting patients on a statin, the best available evidence recommends monitoring adherence but not treating to a specific LDL goal, he said. Statins should not be used in patients older than age 75 unless they have existing ASCVD. The addition of other lipid-modifying drugs is generally not recommended, but it may be needed in patients who demonstrate intolerance to statins. Patients should also avoid using NSAIDS, which raise CVD risk, and instead use medications that lower it, such as aspirin, he said.
Dr. Baron reported having no relevant financial disclosures.
SAN FRANCISCO – In the United States, deaths from cardiovascular disease fell by about 50% in men and women between 1980 and 2000, and fell an additional 31% between 2000 and 2010, according to Robert Baron, MD.
That’s the good news, driven largely by the introduction of statin therapy and by risk-factor modifications. The not-so-great news? The optimal screening age for CVD risk remains elusive.
“We’ve been arguing about this for at least 30 years,” he said at the UCSF Annual Advances in Internal Medicine.
The 2013 American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk recommends screening at age 21 years to identify those with an LDL cholesterol level greater than 190 mg/dL, while a more recent draft recommendation statement from the United States Preventive Services Task Force (USPSTF) recommends screening at age 35 in men and 45 in women for most cases, or at age 20 in people deemed to be at increased risk. Both sets of guidelines recommend the use of statins in patients with atherosclerotic cardiovascular disease, and LDL of 190 mg/dL or greater, and/or diabetes.
“In essence, the USPSTF guidelines are saying definitely use statins for primary prevention in high-risk people; they’re just creating a little more gray area as to what exactly constitutes high risk,” said Dr. Baron, an internist who is associate dean at UCSF Medical Center, San Francisco. “The question is, how do you draw the line? I would argue that depends on the patient preference.”
In a recently published analysis, researchers set out to determine how the USPSTF guidelines compare with the ACC/AHA guidelines in terms of the proportion of U.S. adults potentially treated (JAMA. 2017 Apr 18; 317[15]:1563-7). After using estimates based on data from 3,416 participants in the 2009-2014 National Health and Nutrition Examination Survey, the researchers found that USPSTF recommendations would be associated with statin initiation in 16% of U.S. adults aged 40-75 years without prior CVD, compared with 24% according to the ACC/AHA guidelines.
Among those adults for whom therapy would no longer be recommended under the USPSTF recommendations, 55% are aged 40-59 years with a mean 30-year cardiovascular risk exceeding 30%, and 28% have diabetes. According to Dr. Baron, the comparison “reinforces the primary prevention message. It gives the patient a bit more flexibility.”
After starting patients on a statin, the best available evidence recommends monitoring adherence but not treating to a specific LDL goal, he said. Statins should not be used in patients older than age 75 unless they have existing ASCVD. The addition of other lipid-modifying drugs is generally not recommended, but it may be needed in patients who demonstrate intolerance to statins. Patients should also avoid using NSAIDS, which raise CVD risk, and instead use medications that lower it, such as aspirin, he said.
Dr. Baron reported having no relevant financial disclosures.
EXPERT ANALYSIS FROM THE ANNUAL ADVANCES IN INTERNAL MEDICINE
New drug choices emerging to battle antibiotic resistance
SAN FRANCISCO – When the Infectious Diseases Society of America released the “Bad Bugs, No Drugs” report in 2004, its authors warned that effective antibiotics may not be available to treat seriously ill patients in the near future.
It also proposed legislative, regulatory, and funding solutions with a goal of developing and licensing 10 new antibiotics by the year 2020.
One such advancement was the Generating Antibiotics Incentives Now Act, which was signed into law in 2012 and created a designation for new antibiotics that are used to treat serious and/or life-threatening diseases due to certain pathogens. It also extends the patent life of these antibiotics and allows for fast-track Food and Drug Administration approval.
According to Dr. Erlich, chief of staff and medical director of infection control and antibiotic stewardship at Mills Peninsula Medical Center, Burlingame, Calif., increasingly common antibiotic-resistant pathogens besides MRSA and VRE include penicillin-resistant Streptococcus pneumoniae, extended-spectrum beta-lactamase–producing gram-negative rods, carbapenem-resistant Enterobacteriaceae (CRE), multidrug-resistant Mycobacterium tuberculosis, Salmonella enterica serotype Typhimurium DT 104, and drug-resistant Candida species.
Since 2010, several new antibiotics have been introduced to the market, including three second-generation lipoglycopeptide antibiotics with gram-positive coverage that are approved primarily for skin and soft tissue infections: dalbavancin (Dalvance), telavancin (Vibativ), and oritavancin (Orbactiv).
Compared with vancomycin, these new agents have more convenient dosing and a longer half life, “but they’re also more expensive,” said Dr. Erlich. Dalbavancin can be dosed once a week intravenously, telavancin can be dosed once daily intravenously, and oritavancin requires just one dose.
Another new agent is tedizolid phosphate (Sivextro), a second-generation oxazolidinone that is in the same drug class as linezolid (Zyvox). Tedizolid phosphate has gram-positive coverage including MRSA, but it is not approved for VRE. “It’s FDA approved for skin and soft-tissue infections (SSTI) but can be used for other locations as well,” Dr. Erlich said. “It features once-daily dosing IV or PO.”
Ceftaroline fosamil (Teflaro), ceftolozane/tazobactam (Zerbaxa), and ceftazidime/avibactam (Avycaz) are broad-spectrum cephalosporins with or without beta-lactamase inhibitors resulting in extended gram-negative coverage. FDA-approved indications include complicated urinary tract infections, complicated abdominal infections, SSTI, and pneumonia.
The primary advantage of these drugs, compared with other agents, is for multidrug-resistant gram-negative bacteria such as extended-spectrum beta-lactamase producers and CRE. “We’re not using a lot of these drugs in clinical practice, but they are available for patients with multidrug-resistant gram-negative rods who have no other options,” Dr. Erlich said.
Practical ways that clinicians can prevent antibiotic resistance include prescribing antibiotics only when necessary. “Be aware of local resistance patterns, avoid antibiotics for probable viral infections, use narrow-spectrum choices when possible, use shorter durations when appropriate, and consult published guidelines for optimal empiric antibiotic therapy,” Dr. Erlich advised.
In addition, “advocate infection control measures to keep patients from developing infections, including proper wound care, hand washing, respiratory etiquette, vaccinations, and social isolation for symptomatic individuals,” he noted.
Dr. Erlich reported having no relevant financial disclosures.
SAN FRANCISCO – When the Infectious Diseases Society of America released the “Bad Bugs, No Drugs” report in 2004, its authors warned that effective antibiotics may not be available to treat seriously ill patients in the near future.
It also proposed legislative, regulatory, and funding solutions with a goal of developing and licensing 10 new antibiotics by the year 2020.
One such advancement was the Generating Antibiotics Incentives Now Act, which was signed into law in 2012 and created a designation for new antibiotics that are used to treat serious and/or life-threatening diseases due to certain pathogens. It also extends the patent life of these antibiotics and allows for fast-track Food and Drug Administration approval.
According to Dr. Erlich, chief of staff and medical director of infection control and antibiotic stewardship at Mills Peninsula Medical Center, Burlingame, Calif., increasingly common antibiotic-resistant pathogens besides MRSA and VRE include penicillin-resistant Streptococcus pneumoniae, extended-spectrum beta-lactamase–producing gram-negative rods, carbapenem-resistant Enterobacteriaceae (CRE), multidrug-resistant Mycobacterium tuberculosis, Salmonella enterica serotype Typhimurium DT 104, and drug-resistant Candida species.
Since 2010, several new antibiotics have been introduced to the market, including three second-generation lipoglycopeptide antibiotics with gram-positive coverage that are approved primarily for skin and soft tissue infections: dalbavancin (Dalvance), telavancin (Vibativ), and oritavancin (Orbactiv).
Compared with vancomycin, these new agents have more convenient dosing and a longer half life, “but they’re also more expensive,” said Dr. Erlich. Dalbavancin can be dosed once a week intravenously, telavancin can be dosed once daily intravenously, and oritavancin requires just one dose.
Another new agent is tedizolid phosphate (Sivextro), a second-generation oxazolidinone that is in the same drug class as linezolid (Zyvox). Tedizolid phosphate has gram-positive coverage including MRSA, but it is not approved for VRE. “It’s FDA approved for skin and soft-tissue infections (SSTI) but can be used for other locations as well,” Dr. Erlich said. “It features once-daily dosing IV or PO.”
Ceftaroline fosamil (Teflaro), ceftolozane/tazobactam (Zerbaxa), and ceftazidime/avibactam (Avycaz) are broad-spectrum cephalosporins with or without beta-lactamase inhibitors resulting in extended gram-negative coverage. FDA-approved indications include complicated urinary tract infections, complicated abdominal infections, SSTI, and pneumonia.
The primary advantage of these drugs, compared with other agents, is for multidrug-resistant gram-negative bacteria such as extended-spectrum beta-lactamase producers and CRE. “We’re not using a lot of these drugs in clinical practice, but they are available for patients with multidrug-resistant gram-negative rods who have no other options,” Dr. Erlich said.
Practical ways that clinicians can prevent antibiotic resistance include prescribing antibiotics only when necessary. “Be aware of local resistance patterns, avoid antibiotics for probable viral infections, use narrow-spectrum choices when possible, use shorter durations when appropriate, and consult published guidelines for optimal empiric antibiotic therapy,” Dr. Erlich advised.
In addition, “advocate infection control measures to keep patients from developing infections, including proper wound care, hand washing, respiratory etiquette, vaccinations, and social isolation for symptomatic individuals,” he noted.
Dr. Erlich reported having no relevant financial disclosures.
SAN FRANCISCO – When the Infectious Diseases Society of America released the “Bad Bugs, No Drugs” report in 2004, its authors warned that effective antibiotics may not be available to treat seriously ill patients in the near future.
It also proposed legislative, regulatory, and funding solutions with a goal of developing and licensing 10 new antibiotics by the year 2020.
One such advancement was the Generating Antibiotics Incentives Now Act, which was signed into law in 2012 and created a designation for new antibiotics that are used to treat serious and/or life-threatening diseases due to certain pathogens. It also extends the patent life of these antibiotics and allows for fast-track Food and Drug Administration approval.
According to Dr. Erlich, chief of staff and medical director of infection control and antibiotic stewardship at Mills Peninsula Medical Center, Burlingame, Calif., increasingly common antibiotic-resistant pathogens besides MRSA and VRE include penicillin-resistant Streptococcus pneumoniae, extended-spectrum beta-lactamase–producing gram-negative rods, carbapenem-resistant Enterobacteriaceae (CRE), multidrug-resistant Mycobacterium tuberculosis, Salmonella enterica serotype Typhimurium DT 104, and drug-resistant Candida species.
Since 2010, several new antibiotics have been introduced to the market, including three second-generation lipoglycopeptide antibiotics with gram-positive coverage that are approved primarily for skin and soft tissue infections: dalbavancin (Dalvance), telavancin (Vibativ), and oritavancin (Orbactiv).
Compared with vancomycin, these new agents have more convenient dosing and a longer half life, “but they’re also more expensive,” said Dr. Erlich. Dalbavancin can be dosed once a week intravenously, telavancin can be dosed once daily intravenously, and oritavancin requires just one dose.
Another new agent is tedizolid phosphate (Sivextro), a second-generation oxazolidinone that is in the same drug class as linezolid (Zyvox). Tedizolid phosphate has gram-positive coverage including MRSA, but it is not approved for VRE. “It’s FDA approved for skin and soft-tissue infections (SSTI) but can be used for other locations as well,” Dr. Erlich said. “It features once-daily dosing IV or PO.”
Ceftaroline fosamil (Teflaro), ceftolozane/tazobactam (Zerbaxa), and ceftazidime/avibactam (Avycaz) are broad-spectrum cephalosporins with or without beta-lactamase inhibitors resulting in extended gram-negative coverage. FDA-approved indications include complicated urinary tract infections, complicated abdominal infections, SSTI, and pneumonia.
The primary advantage of these drugs, compared with other agents, is for multidrug-resistant gram-negative bacteria such as extended-spectrum beta-lactamase producers and CRE. “We’re not using a lot of these drugs in clinical practice, but they are available for patients with multidrug-resistant gram-negative rods who have no other options,” Dr. Erlich said.
Practical ways that clinicians can prevent antibiotic resistance include prescribing antibiotics only when necessary. “Be aware of local resistance patterns, avoid antibiotics for probable viral infections, use narrow-spectrum choices when possible, use shorter durations when appropriate, and consult published guidelines for optimal empiric antibiotic therapy,” Dr. Erlich advised.
In addition, “advocate infection control measures to keep patients from developing infections, including proper wound care, hand washing, respiratory etiquette, vaccinations, and social isolation for symptomatic individuals,” he noted.
Dr. Erlich reported having no relevant financial disclosures.
AT THE ANNUAL ADVANCES IN INTERNAL MEDICINE
Bilateral cellulitis on legs? Think venous stasis dermatitis
SAN FRANCISCO – If a patient presents with bilateral cellulitis on both legs, think venous stasis dermatitis, which is the number one misdiagnosis of cellulitis and a frequent cause of unnecessary hospitalization for so-called “red leg,” according to Kanade Shinkai, MD, PhD.
“It’s easy to make that mistake, because you have a red, hot leg that’s painful, and the patient is having difficulty walking,” Dr. Shinkai said at the UCSF Annual Advances in Internal Medicine meeting. “Venous stasis dermatitis is one of the things you want to learn to recognize, as hospitalization is typically not needed.”
“That has to do with the venous return back to the heart,” said Dr. Shinkai, a dermatologist at UCSF Medical Center. “If it’s unilateral, it’s almost always on the left side.”
Patients often have features of venous insufficiency that cause stasis, including varicose veins and brawny hyperpigmentation on the medial aspects of the ankles. “They have almost no systemic features: no fever, no white count, no lymphadenopathy,” she said. “These patients need some kind of anti-inflammatory medication because the skin is very inflamed. If you happened to take a biopsy, you would see inflammation as well as lymphatic congestion.”
Dr. Shinkai recommends that patients apply a midpotency topical steroid such as triamcinolone to the affected area, followed by compression, ideally antiembolism stockings (TED hose) – but that can be a hard sell.
“When your legs are that swollen, they’re really painful to wear,” she said. “Patients will say, ‘Don’t you come near me with those TED hose.’ If you’re in that situation, tell them to use an Ace wrap with light compression and each day tighten the Ace wrap a little more until they are able to use TED hose with minimal discomfort.”
The differential diagnosis for venous stasis dermatitis includes cellulitis (which rarely presents bilaterally), deep vein thrombosis, asteatotic dermatitis, erysipelas (more superficial cellulitis that results in elevated, shiny plaques), pyomyositis, necrotizing fasciitis, leukocytoclastic vasculitis, and allergic contact dermatitis.
Dr. Shinkai reported having no relevant financial disclosures.
SAN FRANCISCO – If a patient presents with bilateral cellulitis on both legs, think venous stasis dermatitis, which is the number one misdiagnosis of cellulitis and a frequent cause of unnecessary hospitalization for so-called “red leg,” according to Kanade Shinkai, MD, PhD.
“It’s easy to make that mistake, because you have a red, hot leg that’s painful, and the patient is having difficulty walking,” Dr. Shinkai said at the UCSF Annual Advances in Internal Medicine meeting. “Venous stasis dermatitis is one of the things you want to learn to recognize, as hospitalization is typically not needed.”
“That has to do with the venous return back to the heart,” said Dr. Shinkai, a dermatologist at UCSF Medical Center. “If it’s unilateral, it’s almost always on the left side.”
Patients often have features of venous insufficiency that cause stasis, including varicose veins and brawny hyperpigmentation on the medial aspects of the ankles. “They have almost no systemic features: no fever, no white count, no lymphadenopathy,” she said. “These patients need some kind of anti-inflammatory medication because the skin is very inflamed. If you happened to take a biopsy, you would see inflammation as well as lymphatic congestion.”
Dr. Shinkai recommends that patients apply a midpotency topical steroid such as triamcinolone to the affected area, followed by compression, ideally antiembolism stockings (TED hose) – but that can be a hard sell.
“When your legs are that swollen, they’re really painful to wear,” she said. “Patients will say, ‘Don’t you come near me with those TED hose.’ If you’re in that situation, tell them to use an Ace wrap with light compression and each day tighten the Ace wrap a little more until they are able to use TED hose with minimal discomfort.”
The differential diagnosis for venous stasis dermatitis includes cellulitis (which rarely presents bilaterally), deep vein thrombosis, asteatotic dermatitis, erysipelas (more superficial cellulitis that results in elevated, shiny plaques), pyomyositis, necrotizing fasciitis, leukocytoclastic vasculitis, and allergic contact dermatitis.
Dr. Shinkai reported having no relevant financial disclosures.
SAN FRANCISCO – If a patient presents with bilateral cellulitis on both legs, think venous stasis dermatitis, which is the number one misdiagnosis of cellulitis and a frequent cause of unnecessary hospitalization for so-called “red leg,” according to Kanade Shinkai, MD, PhD.
“It’s easy to make that mistake, because you have a red, hot leg that’s painful, and the patient is having difficulty walking,” Dr. Shinkai said at the UCSF Annual Advances in Internal Medicine meeting. “Venous stasis dermatitis is one of the things you want to learn to recognize, as hospitalization is typically not needed.”
“That has to do with the venous return back to the heart,” said Dr. Shinkai, a dermatologist at UCSF Medical Center. “If it’s unilateral, it’s almost always on the left side.”
Patients often have features of venous insufficiency that cause stasis, including varicose veins and brawny hyperpigmentation on the medial aspects of the ankles. “They have almost no systemic features: no fever, no white count, no lymphadenopathy,” she said. “These patients need some kind of anti-inflammatory medication because the skin is very inflamed. If you happened to take a biopsy, you would see inflammation as well as lymphatic congestion.”
Dr. Shinkai recommends that patients apply a midpotency topical steroid such as triamcinolone to the affected area, followed by compression, ideally antiembolism stockings (TED hose) – but that can be a hard sell.
“When your legs are that swollen, they’re really painful to wear,” she said. “Patients will say, ‘Don’t you come near me with those TED hose.’ If you’re in that situation, tell them to use an Ace wrap with light compression and each day tighten the Ace wrap a little more until they are able to use TED hose with minimal discomfort.”
The differential diagnosis for venous stasis dermatitis includes cellulitis (which rarely presents bilaterally), deep vein thrombosis, asteatotic dermatitis, erysipelas (more superficial cellulitis that results in elevated, shiny plaques), pyomyositis, necrotizing fasciitis, leukocytoclastic vasculitis, and allergic contact dermatitis.
Dr. Shinkai reported having no relevant financial disclosures.
AT THE ANNUAL ADVANCES IN INTERNAL MEDICINE