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American Gastroenterology Association (AGA) Clinical Practice Obesity Guideline Including Pharmacological Interventions

Summary: 

Obesity, defined by the CDC as a weight that is higher than what is considered healthy for a given height, has been increasing in prevalence over several decades. Roughly two thirds of adults are considered obese or overweight, with a recent estimate putting the prevalence of adults with obesity at nearly 42% of the population. It is customary to use BMI calculations as both a screening tool and to further characterize the degree of obesity, but it is important to note that BMI does not diagnose a patient’s health or even degree of body fat. Healthcare providers should combine appropriate clinical assessments, considering body weight, central fat distribution, functional status, and presence of obesity related complications, to create a more accurate picture of a patient’s health. In recent years we have gained a better understanding of what contributes to obesity and what helps a patient maintain a healthy weight. The AGA has accordingly updated their guidelines on pharmacological interventions for adults with obesity to better help clinicians care for their obese patients.  

Diagnosis 

All adults should be screened for obesity by obtaining a height and weight and calculating BMI during a routine physical exam 

BMI can be calculated via calculator or by dividing weight (kg) over height (m)2 

  • Underweight: <18.5 kg/m 2 
  • Normal weight: ≥18.5 to 24.9 kg/m 2 
  • Overweight: ≥25.0 to 29.9 kg/m 2 
  • Obesity: ≥30 kg/m 2 

Obesity can be further characterized by class 

  • Class I: 30.0 to 34.9 kg/m 2 
  • Class II: 35.0 to 39.9 kg/m 2  
  • Class III: ≥40 kg/m 2 

A BMI over 25 kg/m 2 should prompt further evaluation including 

  • Measurement of waist circumference: > 40 inches in men and > 35 inches in women is associated with increased risk for obesity related complications 
  • Screening for obesity related complications (see below) 
  • Consideration of causes of weight gain not related to diet and activity level (e.g., hypothyroidism, drug side effect, depression, Cushing’s syndrome)  
  • Blood pressure measurement  
  • Fasting glucose and lipid levels 

Note: A BMI > 23 kg/m2 may indicate the need for further evaluation in patients of South Asian, Southeast Asian, and East Asian descent as obesity related complications develop at lower BMIs in these populations 

 Obesity related complications 

  • Type 2 Diabetes Mellitus (T2DM), Prediabetes  
  • Cardiovascular disease 
  • Hypertension 
  • Hyperlipidemia 
  • Obstructive sleep apnea 
  • Obesity hypoventilation syndrome 
  • Nonalcoholic fatty liver disease 
  • Osteoarthritis 
  • Stroke 
  • Certain malignancies (e.g., colorectal cancer, endometrial cancer) 
  • Depression  
  • PCOS, Infertility  
  • GERD  
  • Urinary incontinence 
  • VTE 
  • Gallstones  

Lifestyle Interventions 

The cornerstones of weight loss management are individualized dietary changes and increased physical activity. Recent guidelines, including the USPSTF recommendations, recommend the use of behavioral therapy and a multidisciplinary approach involving weight loss counselors, psychologists, physical therapists and dieticians to assist the patient in establishing and reaching their weight loss goals.  

Weight loss goals should be modest 

  • A weight reduction of 5% to 10% of initial body weight is sufficient to yield significant health benefits including decreased risk of diabetes and cardiovascular disease  
  • A 5% weight loss within 3 months is used by the US Food and Drug Administration (FDA) to assess the efficacy of medications to treat obesity 

Increased calorie expenditure 

  • Adults should perform at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity per week (or an equivalent combination of these)  

Decreased calorie intake 

  • Reducing daily calorie intake to 1200 to 1500 for women and 1500 to 1800 for men  
  • Estimating an individual’s daily energy requirements and aiming for an energy deficit of 500 kcal/d or 750 kcal/d  

Pharmacological Therapies 

In adults with obesity or overweight with weight-related complications, who have had an inadequate response to lifestyle interventions, the AGA recommends adding pharmacological agents to lifestyle interventions over continuing lifestyle interventions alone.

Clinical Considerations 

Anti-obesity medications (AOMs) are not recommended for: 

  • Pregnant women  
  • Patients with bulimia nervosa  

Use caution when starting AOMs for patients with: 

  • Diabetes treated with insulin or insulin secretagogues (e.g., sulfonylureas) as AOMs may decrease blood sugar levels 
  • Hypertension or those on blood pressure lowering agents, as AOMs may lower blood pressure as weight is lost  
  • Binge eating disorder  

Cost of AOMs may limit their access and data on cost-effectiveness is limited 

Recommended Anti-Obesity Medications 

Semaglutide (Wegovy)     

  • Largest magnitude of net benefit, so can be considered first line prior to other drugs 
  • Dosing is started at 0.25 mg/week escalated gradually to goal of 2.4 mg/week 
  • Delays gastric emptying, may cause nausea and emesis which is mitigated by slow taper to goal dose 
  • Can maintain on highest dose tolerated  
  • Contraindications: History of pancreatitis|Hx or FHx of Medullary Thyroid Cancer| Hx of FHx of MEN-2A or MEN-2B 
  • Associated with increased risk of pancreatitis and biliary disease  
  • Used in Diabetes under brand name Ozempic 

Liraglutide (Saxenda)   

  • Escalate dose gradually to a target dose of 3mg daily  
  • Can maintain at highest dose tolerated 
  • Associated with nausea, emesis due to delayed gastric emptying 
  • Associated with increased risk of pancreatitis and biliary disease 
  • Contraindications: History of pancreatitis or FHx of Medullary Thyroid Cancer| Hx of FHx of MEN-2A or MEN-2B 
  • Used in DM under brand name Victoza 

Tirzepatide (Mounjaro) 

  • Not included in AGA guidelines, but promising results from recent trial published in NEJM (see “Primary Sources – Learn More” below)

Phentermine-Topiramate ER (Qsymia) 

  • Useful in patients who also have migraines given the Topamax component  
  • Avoid in patients with cardiovascular disease and hypertension 
  • Monitor HR and BP regularly while on this medicine 
  • Topamax is teratogenic and women of child-bearing age should be appropriately counseled  
  • Pregnancy test should be obtained prior to initiation 
  • Multiple drug interactions exist 

Naltrexone-Bupropion ER (Contrave) 

  • Useful in patients with concomitant depression or desire to quit smoking  
  • Avoid in patients with seizure disorders and those on opiates 
  • Monitor HR and BP regularly while on this medicine 

Orlistat (Xenical) 

  • No longer recommended due to minimal effects and significant GI adverse effects  

Phentermine (Adipex) 

  • Approved by the FDA for short term use (12 weeks) but used off label for chronic weight loss management 
  • Typically not recommended as first line therapy due to side effects and potential for abuse 
  • Avoid in patients with cardiovascular disease 
  • Avoid in patients with history of drug abuse 
  • Monitor HR and BP regularly while on this medicine 

Diethylpropion (Amfepramone) 

  • Approved by the FDA for short term use (12 weeks) but used off label for chronic weight loss management  
  • Typically not recommended as first line therapy due to side effects and potential for abuse 
  • Avoid in patients with cardiovascular disease 
  • Monitor HR and BP regularly while on this medicine 

Future therapies 

Gelesis100 Oral Superabsorbent hydrogel 

  • Space occupying gel to decrease appetite and PO intake 
  • Delivered in the form of a pill with 3 pills take with water prior to lunch and dinner 
  • For patients with BMI of 25 to 40 kg/m 2 
  • Currently in use via clinical trials  

Surgical Management 

While not addressed in the recent AGA guidelines, the AGA did publish guidelines in 2017 that included surgical management options

Bariatric Endoscopy 

  • Intragastric balloon 
  • Aspiration therapy  
  • Endoscopic sleeve gastroplasty 
  • Transoral outlet reduction 

Bariatric Surgery 

  • Laparoscopic sleeve gastrectomy  
  • Laparoscopic Roux-en-Y gastric bypass  
  • Adjustable gastric banding 

Primary Sources – Learn More: 

AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity

Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults US Preventive Services Task Force Recommendation Statement

White Paper AGA: POWER — Practice Guide on Obesity and Weight Management, Education, and Resources

Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline

AJMC: A Review of Current Guidelines for the Treatment of Obesity

CDC: Overweight and Obesity

NEJM: Tirzepatide Once Weekly for the Treatment of Obesity

CDC: Adult BMI Calculator | Healthy Weight, Nutrition, and Physical Activity

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians 

SUMMARY: 

Low back pain is a common complaint in outpatient settings, with an estimated 25% of adults reporting an episode of low back pain lasting for at least one day in the past three months. It is associated with high healthcare costs and is a leading cause of activity limitation and missed worked days globally. The diagnosis of low back pain can be clinically frustrating, with the majority of cases unattributable to a specific cause. The American College of Physicians last released guidelines to aid in diagnosis and treatment of low back pain in 2007, and updated their treatment guidelines in 2017, stressing non-pharmacological therapies for most types of back pain.  

Clinical Presentation  

Diagnosis  

  • Obtain detailed history and physical  
    • Pay attention for signs and symptoms of radiculopathy or spinal stenosis 
    • Assess for other symptoms or illnesses that may contribute to back pain (e.g., history of autoimmune disease, falls, and injuries) 
  • Imaging is typically not recommended for non-specific back pain, and should only be done when it will change management 

Etiologies  

  • Mechanical: Lumbar Strain | Fracture | Osteoporosis | Herniated Disc | Degenerative disc disease  
  • Non-Mechanical: Malignancy | Osteomyelitis | Abscess | Inflammatory arthritis  
  • Visceral: Prostatitis | Endometriosis | Pancreatitis | Nephrolithiasis | Aortic aneurysm 
  • The vast majority of back pain will be non-specific with no obvious etiology 

Definitions  

  • Acute: Pain lasting less than 4 weeks  
  • Subacute: Pain lasting 4 to 12 weeks 
  • Chronic: Pain lasting over 12 weeks 

Treatment for Acute/Sub-Acute Low Back Pain  

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants.

Pharmacologic therapy 

  • No benefit: Tylenol | Systemic steroids 
  • Small benefit 
    • NSAIDs: Improved pain and function | Should be used at lowest effective dose for short periods of time to reduce associated risks (e.g., renal, GI risks)  
    • Skeletal muscle relaxants (SMR): Provided short term pain relief with studies showing no difference in outcomes between different SMRs 
  • Insufficient evidence to determine benefit: Antidepressants | Opioids | Benzodiazepines | Antiepileptics 

Non-Pharmacologic  

  • No benefit: Exercise | Lumbar supports 

Benefit 

  • Improved pain and function: Massage | Heat wrap | Low-level laser therapy (in conjunction with NSAIDs)  
  • Acupuncture improved pain only 
  • Spinal manipulation improved function only  

Insufficient evidence 

  • Transcutaneous electrical nerve stimulation (TENS) | Electrical muscle stimulation | Inferential therapy | Short-wave diathermy | Traction | Superficial cold (ice) | Motor control exercise (MCE) | Pilates | Tai chi | Yoga | Psychological therapies | Multidisciplinary rehabilitation | Ultrasound | Taping  

Note: Clinicians should reassure patients that the vast majority of acute/subacute low back pain improves with time regardless of therapies used 

Treatment for Chronic Low Back Pain  

For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

Non-Pharmacologic Therapy  

Should be used first line due to minimal associated risks compared to pharmacologic therapies  

No benefit: Foot reflexology | Ultrasound | Transcutaneous electrical nerve stimulation (TENS) | Taping  

Benefit 

  • Improved pain and function: Exercise | Motor control exercise (MCE) | Tai chi | Yoga | Psychologic therapies (e.g., progressive relaxation therapy) | Multidisciplinary rehabilitation | Acupuncture | Massage | Low-level laser therapy 
  • Improved pain only: Electromyography biofeedback | Operant therapy | Cognitive behavioral therapy | Spinal manipulation 

Insufficient evidence 

  • Lumbar support | Electrical muscle stimulation | Interferential therapy | Short-wave diathermy | Traction | Superficial heat or cold 

In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. 

Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits out-weigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. 

Pharmacologic Therapy  

No benefit:  

  • TCAs | SSRIs 

Benefit:  

  • NSAIDs: Improved pain with possible small improvement in function. No difference in outcomes between NSAID types. Should be given at lowest effective dose for short periods of time to reduce harm 
  • Opioids: Improved short-term pain and function. No clear difference between opioid types and formulations (e.g., long vs short acting). Tramadol also effective 
  • Benzodiazepines: Specifically, tetrazepam improved pain  
  • SNRIs: Duloxetine improved pain and function  

Insufficient evidence: SMRs | Tylenol | Systemic steroids | Antiepileptics  

Key Points:  

  • Patient should be encouraged to remain active as tolerated despite low back pain 
  • Improvements in pain and function with different therapies (pharmacologic and non-pharmacologic) were small and many studies reviewed had low-quality evidence  
  • Few differences exist between the different pharmacologic and non-pharmacologic therapies outlined above 
  • Providers should use shared decision-making with the patient to choose which therapy would be most likely to help, based on individual patient traits and discussion of risks and benefits 

Primary Sources – Learn More: 

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017

AAD Guidelines for Management of Acne Vulgaris 

Summary: 

Acne vulgaris (AV) is a multifactorial chronic inflammatory skin disease that affects an estimated 50 million people in the United States, including approximately 85% of teenagers. While AV is not life threatening in and of itself, it is associated with significant physical and psychological morbidity and healthcare costs. The American Academy of Dermatology (AAD) has released guidelines for managing acne in adolescents and adults.  

Quick Navigation

Classification and Grading: 

  • Currently no universal classification or grading system in recommended 
  • Despite this, acne is typically divided into mild, moderate and severe categories to help guide treatment and monitor for improvement with therapies 

Mild Acne 

  • Typically limited to scattered comedones without scarring or nodules  
  • First line treatment includes: Benzoyl peroxide (BP) | Topical retinoid | Topical combination (BP +/- Retinoid +/- antibiotic) 
Mild facial acne, DermNetNZ.org 

Moderate Acne 

  • Visually obvious nodules, papules and comedones  
  • First line treatment includes: Topical combination therapy | Oral antibiotic + BP + retinoid | Oral antibiotic + topical antibiotic + BP + retinoid  
Moderate facial acne, DermNetNZ.org 

Severe Acne  

  • Extensive and prominent nodules, papules and comedones with associated scarring  
  • First line treatment includes: Oral antibiotic + topical therapy | Oral isotretinoin  
Severe facial acne, DermNetNZ.org  

Further Testing: 

Microbiologic testing 

  • Not recommend in the absence of suspicion for gram negative folliculitis  
  • Gram negative folliculitis is a rare condition with uniform and eruptive pustules in the perioral and perinasal regions, typically in the setting of prolonged tetracycline use 
  • Endocrinologic testing 
  • Not recommended in the absence of signs of hyperandrogenism 
  • Signs of excess androgen in post-pubertal females include: Irregular periods | Hirsutism| Infertility | PCOS | Androgenic alopecia 

Topical Therapies: 

Benzoyl Peroxide 

  • Assists with prevention of bacterial resistance and increases efficacy of antibiotics, should be initiated when antibiotics are used 
  • Available as cleanser, foams, gels and creams  

Antibiotics 

  • Not recommended as monotherapy due to risk of bacterial resistance  
  • Clindamycin 1% solution or gel is currently the preferred topical antibiotic for 
    acne therapy 
  • Erythromycin may also be used  

Retinoids  

  • Vitamin A derivatives  
  • Includes: Adapalene | Tretinoin | Tazarotene  
  • Tretinoin inactivated by the coadministration of Benzoyl Peroxide so they should be applied at different times of day  
  • Use limited by side effects such as drying, peeling and photosensitivity 
  • Sunscreen recommended to assist with increased photosensitivity 

Azelaic Acid 

  • Good for treatment of post-inflammatory hyperpigmentation 

Dapsone  

  • 5% gel recommended for inflammatory acne 
  • In studies found to work better in women than in men 

Salicylic Acid  

  • Available over the counter in wash off and leave on formulations 
  • Limited data on efficacy 

Systemic Antibiotics: 

  • Antibiotic use should be limited to shortest possible duration (ideally no more than 3 to 4 months) to reduce risk of antibiotic resistance 
  • Switching to topical antibiotics is recommended following oral antibiotic course for maintenance therapy  
  • Not recommended as monotherapy 

Tetracyclines 

  • First line oral antibiotic class  
  • Includes: Doxycycline | Minocycline | Tetracycline 
  • Toxicities include: Photosensitivity | GI distress | Pigment deposition (with minocycline) 

Macrolides 

  • Should be limited to patients unable to take tetracyclines (e.g., pregnant patients)  
  • Includes: Azithromycin | Erythromycin  

Trimethoprim +/- Sulfamethoxazole  

  • Generally, not recommended and should be limited to those unable to take tetracyclines or macrolides  

Beta lactams/Cephalosporins 

  • Limited data, but used occasionally for patients unable to tolerate any of the above 

Hormonal Agents: 

Combined oral contraceptives  

  • Not recommended for certain patients: Pregnant| Breast feeding within 6 weeks of delivery | HTN | Age > 35 and smoker | Diabetes with end organ damage | DM for > 20 years | History of VTE | Heart disease | Prior stroke | Migraines | Liver disease  
  • Otherwise, estrogen containing OCPs are effective for menstruating people with inflammatory acne  
  • 4 combined OCPs approved by FDA for acne therapy: Ethinyl estradiol/norgestimate | Ethinyl estradiol/norethindrone acetate/ferrous fumarate | Ethinyl estradiol/drospirenone | Ethinyl estradiol/drospirenone/levomefolate 
  • Work via an antiandrogen effect  
  • May take several months to take effect on acne 

Spironolactone 

  • Aldosterone receptor antagonist that decreases testosterone production  
  • Recommended for females; male patients had unwanted side effects such as gynecomastia 
  • Effect (and side effects) are dose dependent 
  • Side effects include: Hyperkalemia | Diuresis | Menstrual irregularities | Breast enlargement | Fatigue | Dizziness 

Flutamide 

  • Nonsteroidal selective androgen receptor blocker used in the treatment of prostate cancer; use for acne is not FDA approved  
  • High rates of side effects including: Decreased libido | GI distress | Breast tenderness | Hot flashes | Headaches  

Oral corticosteroids  

  • Can help temporarily for patients with severe inflammatory acne while initiating other therapies  
  • Low dose oral corticosteroids (e.g., Prednisone 5 to 15 mg/day) also recommended for patients with proven adrenal hyperandrogenism  
  • Long term use not recommended  

Isotretinoin: 

  • Recommended for severe nodular acne or acne associated with scarring and significant psychosocial distress 
  • Low dose isotretinoin can be used when side effects limit conventional dosing  
  • Should be taken with food  
  • Routine monitoring recommended of: CBC | LFTs | Cholesterol | Triglycerides  
  • Pregnancy category X: Patients of childbearing age need to be counseled on contraceptive methods 
  • Significant side effects, most commonly: Dry skin | Cheilitis | Dry eyes | Peeling  
  • Patients should be counseled on risks including| Possible development of IBD | Mood changes (e.g., depression, SI) | Agranulocytosis | Elevated LFTs | Elevated triglycerides 

Miscellaneous and Alternative Therapies: 

Chemical peels 

  • Limited evidence for efficacy of routine use of physical modalities 
  • Multiple treatments necessary and results not long lasting  

Intralesional steroids  

  • Effective for treatment of single nodules  

Tea tree oil, herbal remedies 

  • Data limited to support use  

Role of Diet: 

At this time, no dietary changes are recommended for the management of acne 

Glycemic index  

  • High glycemic index diets may be associated with acne 

Dairy 

  • Some emerging data shows dairy intake may influence acne 

Primary Sources – Learn More: 

Journal of American Academy of Dermatology: Guidelines of Care for the Management of Acne Vulgaris

Syphilis: CDC Diagnosis and Treatment Guidelines

WHAT IS IT?

Syphilis is a sexually transmitted infection caused by Treponema pallidum.  Symptoms, diagnostic tests and treatment vary depending on stage of the disease. The syphilis rate has continued to increase in the US over the past decade. Without treatment, syphilis can damage the brain, nerves, eyes, and cardiovascular system.

Screening for Syphilis

Who to Screen

  • The USPSTF task force recommends screening for the following populations (Grade A recommendation: “Offer or provide this service”)
    • Asymptomatic, nonpregnant adolescents and adults who are at increased risk for syphilis infection
    • All pregnant women early in pregnancy
    • Factors associated with increased risk for syphilis include
      • Higher prevalence of infection in particular communities
      • Sociodemographic and behavioral factors (e.g., multiple sex partners, prevalence of syphilis is higher in males, men who have sex with men, drug use, persons living with HIV, young adults, and persons with a history of incarceration, sex work, or military service)

How to Screen

  • Traditional screening: Initial “nontreponemal” antibody test (i.e., Venereal Disease Research Laboratory [VDRL] test or rapid plasma reagin [RPR] test) to detect biomarkers released from damage caused by syphilis infection, followed by a confirmatory “treponemal” antibody detection test (i.e., fluorescent treponemal antibody absorption [FTA-ABS] or T pallidum particle agglutination test [TP-PA])
  • Reverse sequence screening algorithm: Automated treponemal test (such as an enzyme-linked [EIA], chemiluminescence [CIA], or multiplex flow immunoassay [immunoblot]) performed first, followed by a nontreponemal test
    • If the test results of the reverse sequence algorithm are discordant, a second treponemal test (preferably using a different treponemal antibody) is performed

Primary Syphilis

Early disease, characterized by an ulcer or chancre at the infection site approximately 3 weeks after infection

  • Diagnosis
    • Darkfield examination and molecular tests of fluid/tissue for T. pallidum are definitive methods or
    • Presumptive diagnosis requires both a (1) nontreponemal test (VDRL or RPR) and (2) a treponemal test (FTA-ABS, EIA, CIAs and immunoblots, rapid treponemal tests or TP-PA)
  • Treatment
    • Benzathine penicillin G 2.4 million units IM in a single dose

Secondary Syphilis

Symptoms can be diffuse and variable  

  • Symptoms
    • Skin rash (classically with involvement of palms and soles) | Mucocutaneous lesions | Lymphadenopathyn | Fever | Alopecia | Ocular symptoms | Headache | Hepatitis
    •  Typically develops several weeks to months after primary infection
  • Diagnosis
    • Same as for primary syphilis
  • Treatment
    • Same as for primary syphilis

Latent Syphilis

No symptoms and no current evidence of primary, secondary, or tertiary disease

  • Diagnosis of early latent syphilis
    • Documented seroconversion or sustained ( >2 weeks) fourfold or greater increase in nontreponemal test or unequivocal symptoms of primary/secondary syphilis or a sex partner with documented primary/secondary syphilis all within the past year
  • Treatment
    • Early latent (acquired within 1 yr): Benzathine penicillin G 2.4 million units IM single dose
    • Late latent (acquired > 1 yr): Benzathine penicillin G 7.2 million units total given IM in 3 weekly doses of 2.4 million units each

Tertiary Syphilis

Gummas, cardiovascular syphilis (CNS involvement (for neurosyphilis treatment, see below) 

  • Diagnosis
    • Appearance of soft skin lesions and ulcers
    • CXR shows linear calcifications of aorta
    • Perform LP to rule out neurosyphilis
  • Treatment
    • Benzathine penicillin G 7.2 million units administered as 3 weekly doses of 2.4 million units

Neurosyphilis

Note: Can occur at any stage | Includes cranial nerve dysfunction, meningitis, stroke, altered mental status, auditory/ophthalmic abnormalities | Tabes dorsalis and paresis are late manifestations and can occur 10 to 30 years after infection 

  • Diagnosis
    • Lumbar puncture: Test CSF for white blood cell count, protein and VDRL
  • Treatment
    • Aqueous crystalline penicillin G, 3 to 4 million units IV every 4 hours for 10 to 14 days or penicillin G procaine, 2.4 million units IM daily plus probenicid 500 mg orally 4 times daily, for 10 to 14 days

Note: The durations of the recommended and alternative regimens for neurosyphilis are shorter than the duration of the regimen used for latent syphilis | Therefore, benzathine penicillin, 2.4 million units IM once per week for 1 to 3 weeks, can be considered after completion of these neurosyphilis treatment regimens to provide a comparable total duration of therapy

KEY CLINICAL POINTS:

  • Penicillin Allergy
    • Patients with penicillin allergy should be desensitized and treated with penicillin whenever possible
    • Doxycycline 100 mg BID x 14 days or tetracycline 500 mg 4 times daily for 14 days can be used for nonpregnant penicillin-allergic patients with primary or secondary syphilis
  • Counsel patients regarding Jarisch-Herxheimer reaction
    • Acute febrile reaction frequently accompanied by headache, myalgia, and fever
    • Occurs within initial 24 hours after initiation of any syphilis therapy
    • Reaction to treatment and not an allergic reaction to penicillin
    • Occurs most frequently among persons who have early syphilis (likely due to heavier bacterial loads at this stage)
    • Manage with antipyretics
  • Nontreponemal titers decline after treatment and eventually become negative
  • Treponemal tests remain positive for life
  • Follow-up at
    • 6, 12, 18 and 24 months after therapy and should include serology
  • If symptoms persist or recur, or there is a >4 fold increase in nontreponemal test titer persisting more than 2 weeks
    • consider reinfection or treatment failure
    • retreat and check HIV status
  • Sexual transmission occurs only when mucocutaneous lesions are present and is uncommon after the first year
  • Persons exposed sexually to those with primary, secondary or early latent syphilis should be evaluated clinically and serologically

Learn More – Primary Sources:

USPSTF: Screening for Syphilis Infection in Pregnant Women

USPSTF: Screening for Syphilis Infection in Nonpregnant Adolescents and Adults

CDC Sexually Transmitted Diseases: Syphilis

CDC: Syphilis Treatment Guidelines

Review Article: Syphilis Infection during Pregnancy: Fetal Risks and Clinical Management

BMJ Clinical Updates: Syphilis

CDC (MMWR): Missed Opportunities for Preventing Congenital Syphilis — United States, 2022

Depressive Disorders: Diagnosis and Treatment  

SUMMARY:

Depressive disorders are characterized by the presence of a sad, empty, or irritable mood and are accompanied by somatic and cognitive changes that significantly impair a person’s ability to function. Depression due to Major Depressive Disorder is a leading cause of disability worldwide, and the leading risk factor for suicide. In the primary care setting up to 18% of patients have depression and about 9% of the US population meet criteria for depression. Many of these patients are not seen by psychiatrists or psychologists and depend on management and screening by their primary care providers.  

SYMPTOMS: 

  • Depressed mood most of the day, nearly every day (can be self-reported or based on observation of others) 
  • Markedly diminished interest or pleasure in almost all activities most of the day, nearly every day 
  • Change in weight or appetite, either increased or decreased 
  • Change in sleep patterns, either increased or decreased 
  • Psychomotor agitation or retardation 
  • Fatigue or loss of energy 
  • Feelings of worthlessness or excessive guilt 
  • Diminished ability to think, concentrate, or indecisiveness 
  • Recurrent thoughts of death, recurrent suicidal ideation with or without a specific plan, or a suicide attempt 

DIAGNOSIS:

Major Depressive Disorder (MDD) 

  • Depressed mood OR loss of interest/pleasure AND ≥ 4 additional symptoms from above list 
  • Symptoms must be present daily, or nearly every day, during the same 2-week period and represent a change from the previous functioning 
  • Symptoms must cause significant distress or impairment in social, occupational, or other areas of functioning. 
  • Must not be better explained by schizophrenia spectrum disorder, bipolar disorder or be attributable to substance use or medical conditions 

Persistent Depressive Disorder (PDD) – formerly known as dysthymia  

  • Requires a depressed mood AND three or more of the above symptoms for most days for ≥ 2 years 
    • For adolescents, the mood may be irritability and the duration must be ≥1 year 
  • Individuals must not be without the symptoms for > 2 consecutive months during the 2 year (or longer) period  
  • Must not be better explained by schizophrenia spectrum disorder, bipolar disorder or be attributable to substance use or medical conditions 
  • Symptoms must cause significant distress or impairment in some important areas of functioning 

Premenstrual Dysphoric Disorder (PMDD)  

  • Requires  
    • ≥ 5 symptoms that are present in the week prior to menses 
    • Occurs in at least 3 consecutive menstrual cycles 
    • Start to improve within a few days after the onset of menses  
    • Become minimal or absent in the week after menses 
  • One of the symptoms must be a marked change in mood as described by  
    • Affective lability | Irritability or anger | Depressed mood | Anxiety 
  • ≥1 of the following symptoms must be present for a total of 5 symptoms 
    • Decreased interest in usual activities 
    • Difficulty in concentration 
    • Lethargy or lack of energy 
    • Change in appetite or food cravings 
    • Change in amount of sleep 
    • Feeling overwhelmed or out of control 
    • Physical symptoms: e.g., breast tenderness or swelling, join or muscle pain, a feeling of being bloated or weight gain
  • Symptoms must cause significant distress or interference with activities and must not be an exacerbation of another disorder. 

 Adjustment Disorder with Depressed Mood 

  • Low mood | Tearfulness | Feelings of hopelessness  
  • Symptoms occur within 3 months of the onset of an identifiable stressor  
  • Symptoms must be severe enough to cause distress outside of what would be expected, or to impair daily functioning  
  • Cannot meet criteria for other psychiatric disorder (e.g., MDD) 

Substance/Medication-Induced Depressive Disorder  

  • Depressive symptoms associated with the ingestion, inhalation or injection of a substance 
    • Persists beyond the expected length of physiological effects, intoxication or withdrawal period. 

Depressive Disorder Due to Another Medical Condition  

  • Prominent and persistent period of depressed mood or diminished interest in activities that predominates the clinical picture 
    • Thought to be related to the direct physiological effects of another medical condition 
    • Commonly associated medical conditions including hypothyroidism, CVA, Parkinson’s disease and Huntington’s disease 

Other Specified Depressive Disorders 

  • Recurrent brief depression 
    • Depressed mood and 4 other above symptoms for 2 to 13 days every month for the past 12 months 
    • Not associated with the menstrual cycle  
    • Does not meet criteria for other disorders 
  • Short-duration depressive disorder episode 
    • Depressed mood and ≥4 other symptoms for 4 to 13 days 
    • Associated with significant distress or impairment  
    • Does not meet the criteria for other disorders
  • Depressive episode with insufficient symptoms 
    • Depressed mood with ≥1 other symptom with significant distress or impairment that persists for ≥2 weeks  
    • Does not meet the criteria for other disorders
  • Unspecified Depressive Disorder 
    • Depressive symptoms that cause significant distress or impairment  
    • Does not meet the criteria for any other disorder 

Note: Specifiers for Depressive Disorders 

  • With anxious distress 
  • With mixed features 
  • With melancholic features 
  • With atypical features 
  • With psychotic features 
  • With catatonia 
  • With peripartum onset 
  • With seasonal pattern 

Screening 

The USPSTF recommends screening for depression in individuals > 12 years of age when there are systems in place to accurately diagnose and effectively treat, and to provide appropriate follow-up. Individuals with depressive disorders should be evaluated for suicide risk and safety planning should be done when appropriate. 

  • Common Screening Tools 
    • Patient Health Questionnaire (PHQ-9 and PHQ-2)Patient Health Questionnaire (PHQ-9 and PHQ-2)  
    • Geriatric Depression Scale 
    • Edinburgh Postnatal Depression Scale (EPDS) 

Testing 

  • Diagnosis should be made on history according to the DSM-5 criteria listed in the above section | Other diagnosis should be considered based on history and physical exam 
  • Lab work can be considered if certain medical conditions are suspected to be contributing (e.g., TSH | RPR | B12 | CBC) 
  • Patients should be carefully screened for current or past symptoms of manic episodes as this would change diagnosis and medication treatment 
  • Symptoms of psychotic features would affect medication choices 
  • Evaluate for medications or substances that may be affecting mood (e.g. Alcohol | Opiates | Beta blockers)  

KEY POINTS 

  • Depression is a common and debilitating illness that affects a significant number of patients, most of whom seek help from their primary care providers 
  • All adults should be screened for depression via a screening test such as the PHQ-2  
  • Treatment depends on severity of symptoms and includes pharmacotherapy, psychotherapy, or a combination of both  

LEARN MORE – Primary Sources 

VA/DoD Clinical Practice Guidelines – Management of Major Depressive Disorder 

 AFP: Common Questions About the Pharmacologic Management of Depression in Adults 

AACP Updates Treatment Guidelines for Adults with Depression – 2023ACP Updates Treatment Guidelines for Adults with Depression – 2023 

Update from the CDC: Practice Guidelines for Prescribing Opioids 

SUMMARY:  

Pain is one of the most common reasons for a patient to visit their doctor, with one study showing roughly 50% of primary care visits related to a pain complaint. Prescriptions for opioids increased over the 1990s and 2000s, peaking in 2012 and decreasing since, though there remain pockets of high opioid dispensing rates scattered throughout America. As opioid use has become more ubiquitous, the death rate from drug overdoses has also increased steadily, with a sharp rise in deaths during the COVID pandemic. In recent years federal and local governments have attempted to address these worrisome trends with improved funding for resources for the treatment of opioid use disorder, and prevention strategies such as guidelines to help clinicians who prescribe opioids. Following the publication of the 2016 CDC guidelines for prescribing opioids, there was a sharp decrease in opioid prescriptions, with the dispensing rate falling to its lowest level in 15 years. The CDC has recently announced updates to its opioid prescribing guideline and has issued 12 key recommendations and 5 guiding principles to aid in implementation.  

Guiding Principles  

  • Acute (< 1 month), subacute (1 to 3 months), and chronic pain (> 3 months) should be assessed and treated regardless of whether opioids are part of the treatment regimen 
  • Recommendations are voluntary and are intended to be flexible with individualized patient-centered care  
    • Following the 2016 CDC guideline publication there were several studies that demonstrated harm to patients due to provider rigidity over prescribing opioid pain medications, including “untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior” 
  • Use a multimodal and multidisciplinary approach to pain management including behavioral health and social support systems  
  • Avoid misapplying the guideline beyond its intended use or implementing policies derived from the guideline that may lead to harm or untreated pain  
  • Clinicians and health systems should be especially vigilant regarding healthcare inequities in prescribing pain medications 
    • Groups with highest rate of death from drug overdose: American Indian men | Alaska Native men | Black men 
    • In one study examining Medicare beneficiaries with disability, the annual prevalence of prescription opioid receipt was similar among Black and White patients, but Black patients received 36% fewer MME (Morphine Milligram Equivalent).

Tap Here to See MME Calculator

Note: The CDC excludes certain groups from the below recommendations, including those below the age of 18, and pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.  

Key Recommendations  

Initiating Opioids for Pain 

  • Prior to prescribing any opioids 
    • Clinicians should review the patient’s history of opioid use via the state prescription drug monitoring program (PDMP) 

Acute Pain 

  • Nonopioid therapies are at least as effective as opioids for many common types of acute pain  
  • Nonopioid pharmacologic and nonpharmacologic therapies should be maximized prior to initiating opiates for acute pain  
  • Opioids for acute pain should only be given when benefits outweigh risks  
  • Risks of opioid use and possible benefits should be discussed with patient  
  • Acute Pain conditions where nonopioid therapy has been shown to be as effective include 
    • Low back pain | Neck pain | Minor MSK injuries | Minor surgeries | Kidney stones | Migraine  
  • Nonpharmacologic therapies include 
    • Ice | Heat | Elevation | Rest | Immobilization | Exercise | Massage 
  • Nonopioid Pharmacologics include 
    • Tylenol | NSAIDs | Menthol gel | Triptans | Muscle relaxants  

Subacute and Chronic Pain  

  • Nonopioid therapies are preferred for subacute and chronic pain  
  • Maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate  
  • Consider initiating opioid therapy if benefits outweigh risks  
  • Discuss risks and benefits with patient 
    • Establish treatment goals | Make a plan to discontinue if benefits don’t outweigh the risks  
  • Nonpharmacologic therapies include  
    • Physical therapy | Weight loss | Psychological therapy | Spinal manipulation | Low-level laser therapy | Massage | Acupuncture | Cognitive behavior therapy | Mindfulness practices  
  • Nonopioid Pharmacologics include Topical NSAIDS | SNRIs | Tricyclics | Gabapentin | Pregabalin | Capsaicin | Lidocaine patches  

NSAID Use 

NSAIDs should be used at the lowest effective dose and shortest duration needed and should be used with caution, particularly in older adults and in patients with cardiovascular comorbidities, chronic renal failure, or previous gastrointestinal bleeding 

Opioid Drug and Dose Selection 

  • When starting opioids for all pain types (Acute | Subacute | Chronic), begin with immediate release formulations  
    • Extended release/long-acting (ER/LA) opioids should be reserved for severe, continuous pain  
    • Some ER/LA opioids should be reserved for opioid-tolerant patients (Methadone | Fentanyl) 
  • Initiate the immediate release opioids at the lowest effective dosage for opioid-naïve patients  
    • Approximately 5 to 10 MME or a daily dosage of 20 to 30 MME/day  
  • If opioids are continued use caution  
    • Carefully evaluate individual benefits and risks when considering increasing dosage 
    • Avoid increasing dosage above levels likely to yield limited benefits with greater risks  
    • Doses ≥ 50 MME/day yield diminishing returns and progressively increasing risks which should be discussed with patient and carefully considered 
  • Once on opioid therapy, clinicians should carefully weigh benefits and risks when changing opioid dosage 
  • Patients who are at higher risk for adverse events 
    • Sleep apnea | Hepatic dysfunction | CKD/ESRD | Pregnancy | Substance use disorder | >65 years | Work in Safety Critical Jobs | Mental health disorders | Prior overdose 
  • If benefits do not outweigh risks of continued opioid therapy, optimize other therapies while working to gradually taper to lower dosages or appropriately taper and discontinue opioids 
  • Patient agreement is vitally important for a successful taper 
  • Reasons to taper include  
    • Patient request | Pain has improved and underlying cause may have resolved | Misuse | Development of comorbidities that increase risks from opioid use | Side effects diminish quality of life | Side effects impair function | Ongoing therapy has not improved pain | Overdose or serious adverse event has occurred  
  • Tapers of approximately 10% per month or slower are likely to be better tolerated when patients have been taking opioids for longer durations (≥ 1 year)  
  • Tapers of 10% per week may be tolerated for those on opioids for shorter durations (weeks to months)   
  • Do not abruptly discontinue or rapidly reduce to low doses unless there are indications of a life-threatening issue such as concern for impending overdose (e.g., confusion, sedation, slurred speech) 
    • Risks of abrupt withdrawal of opiates include: Acute withdrawal symptoms | Exacerbation of pain | Serious psychological distress | Suicidal ideation 

Duration and Follow Up 

Acute Pain 

  • Prescriptions dispensed for acute pain should contain only enough opioids for the expected duration of pain severe enough to require opioids 
    • For many causes of acute pain an initial opioid prescription of 4 to 7 days’ duration is sufficient 
    • Reevaluate and rule out other causes of pain if patient continues to need opioids for >2 weeks for acute pain

Subacute and Chronic Pain 

  • Reevaluate benefits and risks with patients within 1 to 4 weeks of starting or adjusting dosage of opioid therapy   
  • Interval for follow up after initiating or adjusting opioids should be shorter if  
    • Receiving > 50 MME/day | Starting methadone | Starting ER/LA opioids  
  • For patients on long term opioids follow up is recommended at least every 3 months  

Risk Assessment

  • Periodically during follow up 
    • Rediscuss risks of opioids with patient | Check PDMP to review dosages of opioids received | Discuss strategies to mitigate risk | Offer Naloxone (FDA approved OTC Naloxone spray March 2023) 
  • Consider using toxicology testing annually “to assess for prescribed opioids and other prescription and nonprescription controlled substances that increase risk for overdose when combined with opioids” 
    • Results should be used in a non-punitive manner and testing discussed prior to being undertaken with the patient 
  • Use caution when prescribing opioid pain medication and benzodiazepines together  
    • Consider tapering off benzos prior to initiating opioids  
  • Offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder 
  • Opioid use disorder definition 
    • Defined by the DSM-5 (see ‘Primary Sources – Learn More’ below)   
  • FDA approved medication for opioid use disorder include 
    • Buprenorphine| Methadone | Naltrexone

Primary Sources – Learn More: 

CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 

HHS Overdose Prevention Strategy  

Recent surge in U.S. drug overdose deaths has hit Black men the hardest 

Racial and Ethnic Disparities in Drug Overdose Deaths in the US During the COVID-19 Pandemic 

Racial Inequality in Prescription Opioid Receipt — Role of Individual Health Systems 

Naloxone Prescribing Information  

FDA Approves First OTC Naloxone Spray 

ACP Guideline: Colonoscopy and Interventions to Prevent Recurrence Following Left-Sided Diverticulitis

Summary: 

Diverticula are sac-like protrusions of the colonic wall that tend to occur at increasing rates with older age, with an estimated 50% of adults over the age of 60 developing diverticula. Diverticulosis is defined as the presence of diverticula, and 5 to 10% of patients with diverticulosis will go on to develop symptomatic disease such as diverticulitis, recurrent pain, and bleeding. Following an episode of diverticulitis, a recurrence will occur in 8% to 36% of patients at 1 to 10 years. Additionally, patients who present with complicated diverticulitis – or diverticulitis associated with abscess, bleeding, obstruction, fistula or perforation – have a higher prevalence of colorectal cancer that may be misdiagnosed or missed on initial imaging.  The ACP has put together recommendations regarding follow up care after an episode of left-sided diverticulitis given these increased risks.  

Definitions: 

Uncomplicated Diverticulitis 

  • Left lower quadrant abdominal pain and change in bowel habits associated with localized inflammation of diverticula 
  • No signs or symptoms of sepsis  
  • Immunocompetent patients  

Complicated Diverticulitis  

  • Diverticulitis with at least one of the following: Perforation | Bleeding | Obstruction | Abscess/Phlegmon | Fistula | Immunosuppressed patient  

Colonoscopy for Diagnostic Evaluation: 

“ACP suggests that clinicians refer patients for a colonoscopy after an initial episode of complicated left-sided colonic diverticulitis in patients who have not had recent colonoscopy” 

  • Evidence is inconclusive on whether there is a net benefit in obtaining colonoscopy following uncomplicated diverticulitis  
  • Evidence is also inconclusive on whether there is improved CRC mortality with colonoscopy following complicated diverticulitis  
  • Despite this, ACP recommends colonoscopy following complicated diverticulitis in patients with no recent colonoscopy to rule out CRC given that CRC may present with similar signs and symptoms to complicated diverticulitis  
  • Colonoscopy should be obtained at least 6 to 8 weeks after resolution of diverticulitis  
  • ACP does not define “recent colonoscopy”, but they do not recommend colonoscopy for patients who are otherwise up to date on their CRC screening  
  • Colonoscopy may be most beneficial for those at higher risk of CRC: Older age | Malnutrition | Weight loss | Change in bowel habits | Bloody stool | Persistent abdominal pain  

Interventions to Prevent Recurrence: 

“ACP recommends against clinicians using mesalamine to prevent recurrent diverticulitis” 

  • Diverticulitis is believed to be an inflammatory process, so there was interest in using anti-inflammatory medications to prevent recurrence 
  • Studies reviewed showed no benefit and more discontinuation of drug due to adverse events with mesalamine use  

Dietary Interventions 

  • ACP did not review studies on dietary therapies (e.g. high fiber diet) for reduction of recurrent diverticulitis  
  • A large study in 2008 demonstrated no increased risk for diverticulitis with a diet including nuts, corn, and popcorn, despite the persistence of this belief in the medical community (see  
    Primary Sources – Learn More below)  

“ACP suggests that clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either uncomplicated diverticulitis that is persistent or recurs frequently or complicated diverticulitis. The informed decision whether to undergo surgery should be personalized based on a discussion of potential benefits, harms, costs, and patient’s preferences” 

  • Elective surgery should not be offered to patients with uncomplicated diverticulitis that is not persistent or recurring  
  • Discussion of surgery should include potential harms as 1.4% to 5.5% of surgical patients develop post-op complications (e.g. anastomotic leak, sepsis, MI)  
  • There is no minimum number of recurrences necessary for surgery and discussion should be tailored to the individual patient  
  • Evidence did show decreased rate of recurrent diverticulitis with surgery for patients with: 
    • Complicated or uncomplicated diverticulitis with long term symptoms following acute episode (> 3 months of symptoms)  
    • Complicated or uncomplicated diverticulitis with high rate of recurrence (> or = 3 over 2 years)  

Primary Sources – Read More  

Colonoscopy for Diagnostic Evaluation and Interventions to Prevent Recurrence After Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians 

Nut, corn, and popcorn consumption and the incidence of diverticular disease 

Primary Care Screening: USPSTF Recommendations for Your Patient

Preventive Healthcare Services Recommendations

Courtesy of the US Department of Health and Human Services – AHQR

Enter the following information to obtain screening, counseling and preventive medication recommendations from the USPSTF Preventive Services Database:

  • To view all specific recommendations of the USPSTF leave all search criteria blank and simply click “Submit”
  • All fields are optional
  • When using this tool please read the specific recommendation to determine if the preventive service is appropriate for your patient
  • The “Update Recommendations” button is located below the “Reset” button

This tool is not meant to replace clinical judgment and individualized patient care.

Screening for Sexually Transmitted Infections – Who, When and How Often?

SYNOPSIS:

There are an estimated 2.8 million new chlamydia infections each year in the US and 1.5 million new cases of gonorrhea diagnosed. The highest rates of both gonorrhea and chlamydia are reported in women aged 15 to 24. Symptoms are vague and sequelae can include pelvic inflammatory disease, ectopic pregnancy and infertility.  A full comprehensive sexual history may identify other risk factors to prompt more comprehensive screening for sexually transmitted infections

CLINICAL ACTIONS:

Sexually transmitted infections (STIs) are common with potential for serious long term outcomes, and remain a serious public health concern.  Here, we outline the recommendations for screening for STIs by population:

Adults

  • Annual screening for gonorrhea and chlamydia is recommended for all sexually active women < 25 years | Evidence is insufficient for routine testing of gonorrhea and chlamydia in heterosexual men | Consider screening young men in high prevalence clinical settings e.g., adolescent clinics, correctional facilities, STI/sexual health clinic
    • Re-testing is recommended 3 months after treatment due to high re-infection rates
    • Screening is recommended for adults >25 years old at increased risk for infection (new partner, multiple partners, or a partner who has an STI)
    • Consider testing for rectal chlamydia and pharyngeal gonorrhea based on sexual history practices
    • Annual testing is recommended for men who have sex with men (MSM) at sites of contact (urethra, rectum)and every 3-6 months if at higher risk e.g. MSM on PrEP, HIV infection, or if they or their sex partners have multiple partners
    • Transgender and Gender Diverse Persons screening adapted based on anatomy
  • Screening for syphilis is based on risk profile, with higher risk including history of incarceration, transactional sex work, geography, or male younger than 29 years old
    • Annual screening for sexually active MSM | 3 to 6 months if at increased risk
    • Annual screening for syphilis is recommended in transgender and gender diverse persons
  • Screening for HIV should be performed in all adults aged 13-64 and who seek evaluation and treatment for STIs | Annual HIV screening is recommended for MSM with more than one sexual partner, with consideration for more frequent 3-6 month intervals for testing
  • Consider type-specific HSV serologic testing in patients presenting for an STI evaluation | Note: USPSTF “recommends against routine serologic screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant”
  • Consider screening for trichomonas in high-prevalence settings or patients at higher risk for infection (multiple sex partners, transactional sex, drug misuse, or a history of STI or incarceration)
  • Screening for hepatitis B (HBV) should include all adults aged 18 years and older
    • At least once in their lifetime using a triple panel test
    • Screen pregnant people for hepatitis B surface antigen (HBsAg) during each pregnancy regardless of vaccination status and history of testing
    • Expand periodic risk-based testing to include people incarcerated, people with a history of sexually transmitted infections or multiple sex partners, and people with hepatitis C virus infection
    • Test anyone who requests HBV testing regardless of disclosure of risk
  • Screening for hepatitis C infection (HCV) should include all adults over age 18 years except in settings with HCV positivity < 0.1%
    • All persons with risk factors (eg., persons with HIV, prior recipients of blood transfusions, persons who ever injected drugs and shared needles, and persons who are born to an HCV-infected mother) should be tested for HCV, with periodic testing while risk factors persist

Persons living with HIV

  • At first HIV evaluation and annually afterwards, screen for
    • Gonorrhea
    • Chlamydia
    • Syphilis
    • Hepatitis B surface antigen and Hepatitis B immunity
    • Hepatitis C screening for all persons with HIV and subsequent annual testing for MSM
  • Specifically for women with HIV
    • Screen for trichomonas for women at first evaluation and annually afterwards
    • Women should be screened within 1 year of sexual activity with testing repeat 6 months later | 3 normal and consecutive pap tests, screening can be spaced out to every 3 years

The USPSTF 2021 update

…recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) …recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men

KEY POINTS:

  • Screen sexually active women ≥ 25 for gonorrhea and chlamydia if at increased risk
  • More comprehensive screening for STIs include evaluation for trichomonas, syphilis, HIV, Hepatitis B and Hepatitis C
  • CDC has updated guidelines to recommend universal hepatitis C and hepatitis B screening in all adults

Learn More – Primary Sources:

CDC: Sexually Transmitted Infections Treatment Guidelines 2021

CDC: A Guide to Taking a Sexual History

CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020

CDC: Screening and Testing Recommendations for Chronic Hepatitis B Virus Infection (HBV)

USPSTF: Screening for Hepatitis B Virus Infection in Adolescents and Adults

Map: Prevalence of hepatitis B virus infection

USPSTF: Screening for Chlamydia and Gonorrhea

USPSTF: Serologic Screening for Genital Herpes Infection: US Preventive Services Task Force Recommendation Statement

Patient with Stable CVD: Rivaroxaban, Aspirin or Both to Prevent Recurrent Events?

BACKGROUND AND PURPOSE:

  • Aspirin reduces risk of major CV events by 19% and CV death by 9% in those with CVD
    • 5 to 10% of patients will still have recurrent CV events
  • Eikelboom et al. (NEJM, 2017) assessed whether rivaroxaban, aspirin or both is most effective for secondary cardiovascular event prevention in those with stable atherosclerotic vascular disease

METHODS:

  • Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial
  • 602 centers in 33 countries
  • Double-blind randomized controlled (RCT) trial
  • Inclusion criteria: Coronary artery disease, peripheral arterial disease, or both
  • Participants were randomly assigned to 1 of 3 cohorts
    • Rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg once daily)
    • Rivaroxaban (5 mg twice daily)
    • Aspirin (100 mg once daily)
  • Primary outcome
    • Composite of cardiovascular death, stroke, or myocardial infarction
  • The study was stopped short at 23 month follow-up, due to superiority of the rivaroxaban and aspirin group

RESULTS:

  • Comparing to aspirin-alone group, the rivaroxaban-plus-aspirin group had
    • Fewer patients (4.1% vs 5.4%) with adverse cardiovascular events (hazard ratio [HR] 0.76; 95% CI 0.66 to 0.86; P<0.001)
    • More major bleeding events occurred (3.1% vs 1.9% HR 1.70; 95% CI 1.40 to 2.05; P<0.001)
  • Most major bleeding was into the gastrointestinal tract
  • There was no significant difference in intracranial bleeding, fatal bleeding or bleeding into a critical organ
  • There were 313 deaths (3.4%) in the rivaroxaban-plus-aspirin group as compared with 378 (4.1%) in the aspirin-alone group ([HR] 0.82; 95% CI 0.71 to 0.96; P=0.01; threshold P value for significance, 0.0025)
  • When comparing rivaroxaban-alone group than in the aspirin-alone group, there was no significant difference in primary outcome but there were more major bleeding events

CONCLUSION:

  • Rivaroxaban-plus-aspirin had better cardiovascular outcomes compared to aspirin alone
  • Rivaroxaban alone did not impact outcomes and had more major bleeding events than aspirin alone

Learn More – Primary Sources:

Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease

FDA Drug Safety Communication: Clarithromycin and Increased Potential Risk of Heart Problems or Death in Patients With Heart Disease

SUMMARY:  

FDA released a drug safety advisory and follow-up review, advising caution before prescribing the antibiotic clarithromycin to patients with heart disease because of a potential increased risk of heart problems or death that can occur years later 

  • A review of the results from the CLARICOR trial,  a 10-year follow-up study of patients with stable coronary heart disease from a large clinical trial, observed this serious safety issue 
  • More deaths were observed in patients who underwent a two-week course of clarithromycin that became apparent after ≥1 year of follow up
    • No clear explanation was apparent as to why clarithromycin would lead to more deaths than placebo 
    • Observational studies have been conflicting   
  • The FDA
    • Has added a new warning about this increased risk of death in patients with heart disease that also advises prescribers to consider using other antibiotics in such patients 
    • Has added the study results to the clarithromycin drug labels 
    • Will continue to monitor safety reports in patients taking clarithromycin 
  • FDA recommends the following  

Healthcare professionals should be aware of these significant risks and weigh the benefits and risks of clarithromycin before prescribing it to any patient, particularly in patients with heart disease and even for short periods, and consider using other available antibiotics. Advise patients with heart disease of the signs and symptoms of cardiovascular problems, regardless of the medical condition for which you are treating them with clarithromycin.

KEY POINTS:  

  • Clarithromycin is used to treat many types of infections including
    • Those affecting the skin, ears, sinuses and lungs   
    • Helicobacter pylori 
    • Mycobacterium avium complex (MAC) infection which can be seen in individuals with HIV  
  • In the CLARICOR study, there was increased all-cause mortality and CVD during 10 year follow up, primarily in patients not on statin at entry 
  • FDA recommends that patients talk to their provider about benefits and risks of clarithromycin and any alternative treatments 
  • Patients should
    • Be alert to signs or symptoms of stroke or MI  
    • Should not stop taking medications without medical discussion and oversight  
  • Adverse events or side effects should be reported to FDA’s MedWatch Safety Information and Adverse Event Reporting Program

Learn More – Primary Sources:  

FDA Drug Safety Communication: FDA review finds additional data supports the potential for increased long-term risks with antibiotic clarithromycin (Biaxin) in patients with heart disease

Clarithromycin for stable coronary heart disease increases all-cause and cardiovascular mortality and cerebrovascular morbidity over 10 years in the CLARICOR randomised, blinded clinical trial 

COVID-19: Category Definitions, Symptoms and Those at Increased Risk

NOTE: Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date. This summary has been updated with the latest CDC guidelines on when to end quarantine.

SUMMARY:

The novel coronavirus, named SARS-CoV-2, is the pathogen underlying the pandemic (a global outbreak of disease). The disease associated with this virus has been officially named COVID-19. Coronaviruses represent a large family of viruses. They can cause human illness, but many are found in animals and, rarely, animal coronaviruses can evolve and infect people as was the case in previous infectious outbreaks such as MERS and SARS.



COVID-19 Categories (NIH Panel)

  • Asymptomatic or pre-symptomatic infection
    • Test positive for SARS-CoV-2 using a virologic test (i.e., a nucleic acid amplification test [NAAT] or an antigen test)
    • No symptoms that are consistent with COVID-19
  • Mild illness
    • Have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell)
    • No shortness of breath, dyspnea, or abnormal chest imaging
  • Moderate illness
    • Evidence of lower respiratory disease during clinical assessment or imaging and oxygen saturation (SpO2) ≥94% on room air at sea level
  • Severe illness
    • SpO2 <94% on room air at sea level, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mm Hg, a respiratory rate >30 breaths/min, or lung infiltrates >50%
  • Critical illness
    • Respiratory failure, septic shock, and/or multiple organ dysfunction

Note: SpO2 is a key parameter for defining the illness categories listed above | Pulse oximetry has important limitations (e.g., skin pigmentation, thickness or temperature) | Clinicians who use SpO2 when assessing a patient must be aware of those limitations and conduct the assessment in the context of that patient’s clinical status

Pregnancy: Oxygen supplementation in pregnancy generally used when SpO2 <95% on room air at sea level to accommodate the physiologic needs of mother and fetus

Symptoms

  • Incubation period
    • Time from exposure to development of symptoms: 2 to 14 days
      • Delta variant studies: Mean incubation period of 4.3 days (see ‘Learn More – Primary Sources Below) which was shorter than initial variants (5.0 days)
      • Omicron variant studies: Median incubation period of 3 to 4 days
  • Signs and Symptoms
    • Fever or chills
    • Cough
    • Shortness of breath or difficulty breathing
    • Fatigue
    • Muscle or body aches
    • Headache
    • New loss of taste or smell
    • Sore throat
    • Congestion or runny nose
    • Nausea or vomiting
    • Diarrhea
  • Additional points regarding presentation
    • Older adults: Especially those with comorbidities may have delayed presentation of fever and respiratory symptoms
    • Fatigue, headache, and muscle aches (myalgia) are among the most commonly reported symptoms in people who are not hospitalized
    • Sore throat and nasal congestion or runny nose (rhinorrhea) also may be prominent symptoms
    • GI symptoms may be relatively common
      • Nausea, vomiting or diarrhea may occur prior to fever and lower respiratory tract signs and symptoms
    • Loss of smell (anosmia) or taste (ageusia) has been commonly reported, especially among women and younger or middle-aged patients

Those at Risk Based on Evidence (CDC)

  • Age
    • The CDC states

Age is the strongest risk factor for severe COVID-19 outcomes. Approximately 54.1 million people aged 65 years or older reside in the United States; in 2020 this age group accounted for 81% of U.S. COVID-19 related deaths, and as of September 2021 the mortality rate in this group was more than 80 times the rate of those aged 18-29

Higher Risk: Meta-analysis or systematic review demonstrates good or strong evidence

  • Asthma
  • Cancer
  • Cerebrovascular disease
  • Chronic kidney disease*
  • Chronic lung diseases limited to
    • Interstitial lung disease
    • Pulmonary embolism
    • Pulmonary hypertension
    • Bronchiectasis
    • COPD (chronic obstructive pulmonary disease)
  • Chronic liver diseases limited to
    • Cirrhosis
    • Non-alcoholic fatty liver disease
    • Alcoholic liver disease
    • Autoimmune hepatitis
  • Cystic fibrosis
  • Diabetes mellitus, type 1 and type 2*‡
  • Disabilities‡
    • Attention-Deficit/Hyperactivity Disorder (ADHD)
    • Cerebral Palsy
    • Congenital Malformations (Birth Defects)
    • Limitations with self-care or activities of daily living
    • Intellectual and Developmental Disabilities
    • Learning Disabilities
    • Spinal Cord Injuries
  • Heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies)
  • HIV (human immunodeficiency virus)
  • Mental health disorders limited to
    • Mood disorders, including depression
    • Schizophrenia spectrum disorders
  • Neurologic conditions limited to dementia‡
  • Obesity (BMI ≥30 kg/m2 or ≥95th percentile in children)*‡
  • Primary Immunodeficiencies
  • Pregnancy and recent pregnancy
  • Physical inactivity
  • Smoking, current and former
  • Solid organ or hematopoietic cell transplantation
  • Tuberculosis
  • Use of corticosteroids or other immunosuppressive medications

Suggestive Higher Risk: Underlying medical condition or risk factor that neither has a published meta-analysis or systematic review nor completed the CDC systematic review process

  • Children with certain underlying conditions
  • Down syndrome
  • HIV (human immunodeficiency virus)
  • Neurologic conditions, including dementia
  • Overweight (BMI ≥25 kg/m2, but <30 kg/m2)
  • Sickle cell disease
  • Solid organ or blood stem cell transplantation
  • Substance use disorders
  • Use of corticosteroids or other immunosuppressive medications

Comorbidities with mostly case series, case reports, or, if other study design, the sample size is small 

  • Overweight (BMI ≥25 kg/m2, but <30 kg/m2)
  • Sickle cell disease
  • Substance use disorders
  • Thalassemia

Mixed Evidence: Meta-analysis or systematic review is inconclusive, either because the aggregated data on the association between an underlying condition and severe COVID-19 outcomes are inconsistent in direction or there are insufficient data

  • Alpha 1 antitrypsin deficiency
  • Bronchopulmonary dysplasia
  • Hepatitis B
  • Hepatitis C
  • Hypertension*

Footnotes:

* indicates underlying conditions for which there is evidence for pregnant and non-pregnant people

‡ underlying conditions for which there is evidence in pediatric patients

Learn More – Primary Sources:

Underlying Medical Conditions Associated with Higher Risk for Severe COVID-19: Information for Healthcare Providers

NIH: Clinical Spectrum | COVID-19 Treatment Guidelines

Impact of SARS-CoV-2 Delta variant on incubation, transmission settings and vaccine effectiveness: Results from a nationwide case-control study in France (Lancet Regional Health, 2022)

CDC: Clinical Presentation | Clinical Care Considerations

CDC Coronavirus Disease 2019: Overview of Testing for SARS-CoV-2

Clinical Questions about COVID-19: Questions and Answers

WHO: Novel coronavirus Information Page

JAMA: Coronavirus Disease 2019

FDA: Coronavirus Disease 2019

BMJ: Coronavirus Updates

Lancet: Coronavirus Hub

NEJM: 2019 Novel Coronavirus

Annals of Internal Medicine: Content Related to Coronavirus in Annals of Internal Medicine

JAMA: What Is a Pandemic?

Aluminum and Vaccines – The Evidence for Continuing Safety

SUMMARY:

Aluminum has been present in vaccines as an adjuvant for over 70 years. By boosting immune response, aluminum reduces the amount of vaccine required to provide immunity. In the US, the two aluminum salts that are used are monophosphoryl A (a detoxified bacterial component), and squalene (a compound of the body’s normal cholesterol synthesis pathway).  Aluminum in vaccines has an excellent safety record and according to the FDA,

The risk to infants posed by the total aluminum exposure received from the entire recommended series of childhood vaccines over the first year of life is extremely low, according to a study by the U.S. Food and Drug Administration (FDA).

Supporting Data

  • The FDA (Vaccine, 2011) specifically addressed the issue of aluminum and vaccines due to public concern
  • Using the most current infant exposures and research on the pharmacokinetics of aluminum, they calculated that an infant would be exposed over the first year of life to a maximum of 4.225 mg
    • Based on minimal risk levels established by the ATSDR, the aluminum exposure to vaccines in the first year of life is well below this threshold
    • Multiple other studies have similarly validated the safety profile of aluminum in vaccines (See CHOP reference summary in ‘Learn More – Primary Sources’ below)

Aluminum in Context

  • Third most abundant element after oxygen and silicon
  • Most abundant metal, making up almost 9 percent of the earth’s crust
  • Found in multiple foods and vegetables, aside from storage containers
  • Typical adult exposure is 7 to 9 mg/day

Aluminum Levels in Vaccines

  • The aluminum in vaccines is similar to a liter of infant formula
  • Infants receive approximately 4.4 milligrams of aluminum in the first six months of life from vaccines, which is less than they receive through diet
    • Breast-fed infants ingest about 7 milligrams
    • Formula-fed infants ingest about 38 milligrams
    • Soy formula-fed infants ingest almost 117 milligrams of aluminum during the first six months of life

Recent Publication Linking Aluminum in Vaccines to Autism

  • A recent publication by Li et al. (Journal of Inorganic Biochemistry 2017) exposed mice to aluminum vaccine adjuvants
  • When compared to control mice, certain genes were over and under expressed in the mice that received aluminum injections
  • In one example, the downregulation of NF-κB inhibitor resulted in the activation of the inflammatory pathways and released cytokines
  • The authors claim these findings are ‘consistent with those in autism’ and that aluminum adjuvant promotes brain inflammation

Study Retraction

  • Based on concerns that images in the Li et al. study may have been altered, John Dawson, the editor of the Journal of Inorganic Biochemistry, told ‘Retraction Watch’ that

The paper by Shaw and co-workers is being retracted jointly by the authors and the editor

Read more on the pending retraction at ‘Retraction Watch’ (see ‘Learn More’ below)

Other Study Limitations Beyond Altered Images

  • Assumption that immune changes in mice brain adequately represent the underlying mechanism of autism in humans is unproven
  • Mice used for these studies were not strains associated with autism
  • Mice received 6 vaccine doses earlier in development then humans and over a few days compared to human vaccine which is scheduled over months
  • For ease of experiment, injections were subcutaneous not intramuscular
    • In the FDA study (Vaccine, 2015), the authors point out that intramuscular injection results in a depot effect with different kinetics than other routes of aluminum administration
  • Genetic experiments  are very dated
    • Current methodology for gene expression is gene profiling, which is quantitative and looks at thousands of genes at the same time to understand gene/gene interactions due to complexity of pathways
    • In this study, very few genes selected (based on old literature) and technology is no longer in use for expression in most laboratories as the older method is not truly quantitative
      • Lack of precise quantification make study images difficult to accurately interpret

Read more on the limited quality of the Li et al. paper at ‘Science Blogs’  (see ‘Learn More’ below)

KEY POINTS:

  • There is no clear evidence that inflammation causes autism
  • Vaccines prevent inflammation by preventing significant infectious diseases
  • Not all vaccines contain adjuvants
  • According to the CDC, Aluminum is present in U.S. childhood vaccines that prevent hepatitis A | Hepatitis B | Diphtheria-tetanus-pertussis (DTaP, Tdap) | Haemophilus influenzae type b (Hib) | Human papillomavirus (HPV) and pneumococcus infection.
  • Monophosphoryl lipid A is included in one human papillomavirus (HPV) vaccine, Cervarix. One licensed pandemic influenza vaccine contains an adjuvant called AS03. It is included in the US pandemic influenza vaccine stockpile, but it is not available to the general public.
  • Fluad is a newly-licensed flu vaccine that contains MF59 as an adjuvant. MF59 is an oil-in-water emulsion that boosts the body’s immune response to this vaccine. In some vaccines, the weakened or inactivated virus stimulates a strong immune response so no additional adjuvant is needed for it to be effective to protect against infections.  
  • In the United States, vaccines against measles | Mumps | Rubella | Chickenpox | Rotavirus | Polio | And seasonal influenza vaccines do not contain added adjuvants.

Learn More – Primary Sources:

Updated aluminum pharmacokinetics following infant exposures through diet and vaccination 

FDA Study Reports Aluminum in Vaccines Poses Extremely Low Risk to Infants

CDC: ATSDR Minimal Risk Levels (MRLs) 

Updated aluminum pharmacokinetics following infant exposures through diet and vaccination 

Subcutaneous injections of aluminum at vaccine adjuvant levels activate innate immune genes in mouse brain that are homologous with biomarkers of autism

ScienceBlogs: Torturing more mice in the name of antivaccine pseudoscience, 2017 aluminum edition 

Retraction Watch: Journal to retract paper called “anti-vaccine pseudoscience”

Children’s Hospital of Philadelphia: Vaccine Ingredients – Aluminum

ACC/AHA Blood Pressure Guideline: Current Classification System and Treatment Targets

SUMMARY:  

The USPSTF released its latest recommendation regarding screening for hypertension in adults (2021). Based on current evidence demonstrating high certainty regarding net benefit, the task force reaffirms and “recommends screening for hypertension in adults 18 years or older with office blood pressure measurement. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. (grade A recommendation)”.

The ACC/AHA task force report represents the work of several professional bodies based upon hundreds of studies.  There are notable changes from previous practice guidelines, especially related to screening and detection.  The ACC/AHA task force recommends the following classification system:

<120 mmHg and <80 mmHg: NORMAL BP

  • Healthy lifestyle choices  
  • Yearly check-ups 

120 to 129 mmHg and <80 mmHg: ELEVATED BP

  • Healthy lifestyle changes  
  • Reassess in 3 to 6 months  

130 to 139 mmHg or 80 to 89 mmHg: HIGH BP to STAGE 1  

  • 10-year heart disease and stroke risk assessment <10% risk 
    • Lifestyle changes  
    • Re-assess in 3 to 6 months 
  • 10-year heart disease and stroke risk assessment ≥10% risk 
    • Lifestyle changes  
    • Medication  
    • Monthly follow-up until BP is under control 

≥140 mmHg or ≥90 mmHg: HIGH BP – STAGE 2 

  • Lifestyle changes  
  • Consider initiation of therapy with 2 different classes of medications 
  • Monthly follow-up until BP is under control
  • If BP ≥160/100 mm Hg: Treat promptly, monitor carefully and adjust medication dose upward as necessary to achieve control  

NOTE: Calculate 10-year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk (see ‘Learn More – Primary Sources’ below)

Additional Hypertension Classifications  

‘White Coat’ hypertension 

  • Elevated BP in the office but not outside the office  
  • Checking for ‘White Coat’ hypertension using either daytime Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM) is “reasonable” if  
    • Office SBP is >130 but <160 mm Hg or  
    • Office diastolic BP (DBP) >80 but <100 mm Hg and  
    • Patient has failed to improve with 3 months of lifestyle modification  

‘Masked’ hypertension 

  • Elevated BP out-of-office but not in-office 
  • Checking for ‘masked’ hypertension with daytime ABPM or HBPM is “reasonable if”  
    • Office SPB is 120 to 129 and DBP is <80 while not on antihypertensive medications or 
    • If patient is on antihypertensive therapy with office SPB of 120 to 129 and DBP is <80, and they have high risk comorbidities such as CKD, >10% risk of stroke, or signs of hypertension related end organ damage  

Acute severe hypertension 

  • Severe hypertension: SBP ≥180 mmHg or DBP ≥120 mmHg with end organ damage (e.g., pulmonary edema, cardiac ischemia, neurologic deficits, acute renal failure, aortic dissection, and eclampsia) is termed hypertensive emergency. This is a medical emergency that requires hospital care.   
  • If no evidence of end organ damage this is termed hypertensive urgency can manage in ambulatory setting with close follow up   
  • Blood pressure should not be decreased abruptly to prevent cerebral hypoperfusion 

Resistant hypertension 

  • Uncontrolled BP despite treatment with ≥3 antihypertensive agents of different classes (one of which is usually a diuretic) 

The ACC/AHA task force also recommends the following as cut offs for hypertension when using at home BP measurements: >110/>65 mmHg for nighttime mean and >125/>75 mmHg for 24hr mean.  

NOTE: Calculate 10-year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk (see ‘Learn More – Primary Sources’ below) 

KEY POINTS:  

Risk Factors   

  • Genetic predisposition  
    • Complex polygenic disorder  
    • Rarely single gene disorder (e.g. Liddle’s or Gordon’s syndrome) 
  • Environmental Risk Factors  
    • Overweight and Obesity 
    • Sodium Intake 
    • Potassium  
      • Higher levels appear to blunt sodium effect on BP  
      • Lower sodium/potassium ratio may reduce risk of CVD  
    • Physical fitness  
      • Even modest levels of physical activity is associated with a decrease in the risk of incident hypertension  
    • Alcohol 
      • In US, may account for 10% of BP burden  
      • Also associated with higher HDL and at modest intake range, lower risk for CHD when compared to abstinence 

Non-pharmacological Interventions 

  • Weight loss 
    • Goal: Optimum goal is ideal body weight but can expect 1mm Hg for every 1kg reduction 
  • Diet 
    • DASH diet: Fruits and vegetables, whole grains, low-fat dairy products, reduced saturated and total fat 
    • Other diets with supportive evidence 
      • Low in calories from carbohydrates  
      • High-protein diets  
      • Vegetarian diets  
      • Mediterranean dietary pattern  
    • Sodium: Goal <1500 mg/d, but aim for at least a 1000mg/d reduction 
    • Potassium: Goal 3500 to 5000 mg/d, preferably through diet 
  • Exercise – Recommend structured exercise program  
    • Aerobic: 90 to 150 min/wk; 65% to 75% heart rate reserve 
    • Dynamic resistance and Isometric resistance also shown to lower BP  
  • Alcohol Reduction (drink = 12 oz regular beer [5% alc] / 5 oz wine [12% alc] / 1.5 oz distilled spirits [40% alc])  
    • Women: ≤ 1 drink per day  
    • Men: ≤ 2 drink per day 

Taking a BP 

  • Prep 
    • Avoid caffeine, exercise, smoking at least 30 minutes before  
    • Empty bladder 
    • No talking while measurement is taken 
    • Remove clothing covering cuff placement 
    • Patient should sit on chair, feet on floor and back supported for > 5 min before taking pressure (not lying or sitting on an exam table) 
  • Technique 
    • Validated device 
    • Support arm 
    • Middle of cuff on upper arm at level of atrium (midpoint of the sternum) 
    • Cuff size: Bladder should encircle 80% of the arm  
    • Can use either stethoscope diaphragm or bell 
  • Taking the measurement 
    • First visit: Record BP in both arms and use arm with higher reading for subsequent measurements  
    • Separate measurement by 1 to 2 minutes 
    • To estimate systolic BP, use radial pulse obliteration and then inflate cuff 20 to 30 mmHg higher  
    • Deflate cuff pressure 2 mmHg per second and listen for Korotkoff sounds  
      • Systolic BP: First Korotkoff sound 
      • Diastolic BP: Disappearance of all Korotkoff sounds  
      • Use nearest even number  
    • Note time of most recent BP medication before taking measurements  
  • Average the readings to estimate BP 
    • Use average of ≥ 2 readings obtained on ≥ 2 occasions  

Note: The AHA has released a scientific statement that validated oscillometric devices allow accurate BP measurement in the outpatient setting, while reducing human errors associated with the auscultation.  

Target BP Goal  

  • Known CVD or 10-year heart disease and stroke risk assessment ≥ 10% risk 
    • 130/80 
  • Without additional markers of increased CVD risk, a BP target of less than 130/80 mm Hg may be reasonable 

Adults ≥ 65 years 

  • Treat to same goal of <130/80 as younger adults  
  • Recommendation differs with ACP goal of <150/90 and AAFP goal of <140/90 

Pregnancy Recommendations

  • Women with hypertension who become pregnant, or are planning a pregnancy should be transitioned to methyldopa, nifedipine, and/or labetalol during pregnancy
  • Do not treat women with hypertension in pregnancy with ACE inhibitors, ARBs, or direct renin inhibitors

Oral Contraceptives and NSAIDs

  • Oral contraceptives and NSAIDs are listed as commonly used medications that may cause elevated BP
  • The ACC/AHA guideline recommends the following

 OCPs

Use low-dose (e.g., 20 to 30 mcg ethinyl estradiol) agents or a progestin-only form of contraception, or consider alternative forms of birth control where appropriate (e.g., barrier, abstinence, IUD)

Avoid use in women with uncontrolled hypertension

NSAIDs

Avoid systemic NSAIDs when possible

Consider alternative analgesics (e.g., acetaminophen, tramadol, topical NSAIDs), depending on indication and risk

Learn More – Primary Sources:

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults – A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement

10-year risk calculator using ASCVD algorithm

AHA AMA: BP Treatment Algorithm 

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association

2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures

Major CMS Change Regarding Medical Student Documentation

SUMMARY:

The Centers for Medicare & Medicaid Services (CMS) has made a major revision to the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1 that updates the policy on documentation with respect to medical students. According to CMS, this revision will

…allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.

What New Provider Action is Needed?

  • Previously, teaching physicians were required to re-document the medical student’s Evaluation and Management (E/M) documentation
  • With this revision, the teaching physician can verify in the medical record any student documentation of components of E/M services

KEY POINTS:

  • The CMS states that this change was “part of a broader goal to reduce administrative burden on practioners.”
  • This change addresses concerns by medical education professionals and organizations that medical students entering residencies be familiar with documentation, particularly the use of electronic health records
    • The ACP had passed resolution 3-F15 in 2015, calling on

CMS to change the 2008 guidelines to allow teaching physicians to refer to a student’s documentation of the history and physical examination findings or medical decision making in his or her personal note for documentation of an E&M service

  • Billing departments should be made aware of these new changes

Medicare Claims Processing Manual

Changes in bold italics

Chapter 12-100.1.1 – Evaluation and Management (E/M) Services (Rev. 3971, Issued: 02- 02- 18, Effective: 01-01-18, Implementation: 03- 05-18) B. E/M Service Documentation Provided By Students Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.

Learn More – Primary Sources:

CMS Medical Learning Network: E/M Service Documentation Provided By Students (Manual Update)

CMS Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners