Monday, January 26, 2015

Treating interstitial cystitis: pharmacologic and non-pharmacologic options

- Jennifer Middleton, MD, MPH

An estimated 4 million adults in the United States have interstitial cystitis (IC), a syndrome that can cause a variety of bothersome and uncomfortable urinary tract symptoms. The January 15 issue of AFP reviews the evidence base for treating IC; although researchers have yet to identify an effective long-term pharmacologic treatment, two short-term medication options exist with different effects on symptom scores.

This AFP FPIN Clinical Inquiry examined a systematic review from 2007 as well as a couple of more recent randomized controlled trials. The systematic review found heterogenity in study design and outcomes among included randomized controlled trials (RCTs), and the mean duration of these RCTs was only 15 weeks. The FPIN authors note that, in 6 studies, pentosan improved overall symptom scores ("better or worse than prior the intervention") but did not improve scores for specific symptoms like dysuria, urgency, or frequency.

Although the systematic review authors included a small 2001 RCT investigating cimetidine in their tables, they did not comment on it in their manuscript; the FPIN authors, however, had more interest in this study that randomized 36 participants to treatment with cimetidine versus placebo. Although the n is quite small, this RCT did show improvement in overall symptom scores as well as in the specific symptoms of nocturia and suprapubic pain.

Family physicians seeking to help their patients with IC may want to base their medication choice on each patient's symptoms. Although pentosan has been best studied for overall symptoms, cimetidine may be a useful alternative for patients whose predominant symptoms are nocturia and/or suprapubic pain.

Although the American Urological Association (AUA) recommends the use of amitriptyline for IC, the FPIN authors found conflicting evidence. While a smaller RCT (n = 50) showed benefit, a larger RCT (n = 271) did not. The AUA, however, lists all pharmacologic options for IC as second-line treatments, advising patient education, "self-care practices," "behavioral modification," and "stress management practices" as first-line treatments.

In line with those recommendations is a recent study that found a high rate of co-morbid mood symptoms in patients with IC. This 2015 study looked at the association between IC and symptoms of depression, anxiety, and/or insomnia; correlation does not necessarily equal causation, of course, and it's unclear if these symptoms co-exist with IC, predate IC, or come as a result of the frustrating symptoms of IC. Regardless, the hazard ratios (HR) for co-morbid depression, anxiety, or insomnia were 2.4, 2.4, and 2.1, respectively (all HRs had narrow 95th percentile confidence intervals). Although no studies to date have looked at mood treatments for IC, perhaps these studies are not far off given this association. In the meantime, family physicians can at least screen for and treat these co-morbid mood disorders.

If you'd like to read more, there's an AFP By Topic on Urinary Tract Infections/Dysuria that includes this 2011 AFP article on diagnosing and treating IC.

How do you care for patients with IC?

Wednesday, January 21, 2015

Are treatment recommendations for influenza evidence-based?

- Kenny Lin, MD, MPH

As the Centers for Disease Control and Prevention (CDC) reported that people who received this season's influenza vaccine were only 23 percent less likely to be diagnosed with influenza than unvaccinated persons, CDC director Tom Frieden was publicly urging high-risk patients and their physicians to use antiviral medications to prevent complications and disease transmission:

People who are sick with flu, if they're very sick in the hospital or if they have underlying, chronic medical conditions, like asthma, diabetes, heart disease, women who are pregnant, children under two and people over the age of 65 - all of these people, if they get flu, should get treated with antiviral drugs. The evidence indicates that it will shorten how long you're sick, might keep you out of the hospital and could even save your life. ... There is some evidence that suggests that taking antiviral medications may reduce the risk that you'll spread the disease to others in your family so it may be helpful for others as well as for yourself.

A previous AFP Community Blog post discussed a 2012 Cochrane review which cast doubt on the ability of the neuraminidase inhibitors oseltamivir and zanamivir to prevent influenza transmission, noting that after including data from unpublished, industry-sponsored, randomized controlled trials, the difference was not statistically significant.

Also in that year, a meta-analysis by AFP Deputy Editor Mark Ebell and colleagues concluded: "There is no evidence that oseltamivir reduces the likelihood of hospitalization, pneumonia or the combined outcome of pneumonia, otitis media and sinusitis." The authors noted that two large unpublished trials of oseltamivir in older persons and persons with chronic disease did not even show that the drug reduced the duration of symptoms, suggesting that oseltamivir might be less effective at treating influenza in high-risk groups.

In 2014, after gaining access to the complete clinical study reports from the manufacturers, the Cochrane Collaboration updated its previous review and drew the following conclusions: "Oseltamivir and zanamivir have small, non-specific effects on reducing the time to alleviation of influenza symptoms in adults, but not in asthmatic children." Taking either of the drugs did not reduce hospitalizations or serious complications, but did increase risk of nausea, headaches, and psychiatric symptoms. The CDC responded that their recommendations for antiviral medications "remained unchanged," arguing that observational studies not considered in the Cochrane review supported prescribing neuraminidase inhibitors for high-risk patients with influenza.

The bottom line for family physicians is that at best, antiviral medications for influenza have modest benefits that need to be balanced against potential adverse effects in deciding whom to treat. Also, existing evidence does not support the CDC's contention that antivirals are more likely to be beneficial in high-risk populations.

Monday, January 12, 2015

Uncovering eating disorders: history-taking tips

- Jennifer Middleton, MD, MPH

Eating disorders affect up to 24 million U.S. teens and adults, and an article in the January 1 AFP discusses the "Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and Bulimia Nervosa." The well-known clinical signs of eating disorders, including marked weight change, amenorrhea, edema, and arrythmia, are reviewed in Table 3 of this article. Identifying eating disorders in patients whose disease has not yet progressed to this level of severity is more challenging, yet identifying eating disorders earlier in their course is associated with better outcomes for patients.

Since we often enjoy long-term relationships with patients and their families, family physicians can be well-attuned to subtle changes or concerns in patients that may raise our suspicion of an eating disorder prior to any obvious physical complaints or symptoms. Finding the right words or language to investigate further, however, may feel challenging.

An article from 2012 in Current Problems in Pediatric and Adolescent Health Care provides a comprehensive guide to history-taking in adolescents with suspected eating disorders that is also applicable to adults. Directed questioning regarding specific behaviors, done in a supportive and non-judgmental manner, is most likely to be effective. Examples of how to word these questions include:
  • What has been going on with your health and your body? What are your biggest concerns?
  • What do you think you ought to weigh?
  • How much of your day is spent on food/body thoughts?
  • Have you ever tried to change your weight or body? What have you tried?
  • How stressed are you if you miss a workout?
  • What foods do you avoid? Any taboo or fear foods (ones you used to eat that you now avoid)?
  • Do you count calories and/or fat grams? If so, how many do you allow yourself of each?
  • Has anyone ever bullied or teased you? 
A Curbside Consultation from AFP published in 2008 provides additional tips for dealing with challenging parent-adolescent interactions related to eating disorders. The author recommends beginning the visit with both the parent and the adolescent patient, as parents may, initially, be more likely to share details related to disordered eating behaviors than teens. Speaking with the adolescent privately is also of importance, though; asking direct questions like those outlined above may yield additional information that teens may be unwilling to discuss in front of their parents. 

It's estimated that only 10% of individuals with eating disorders receive treatment. Most patients with eating disorders are reluctant to seek help, yet individuals with eating disorders have increased health-care utilization before their diagnosis. Patients with undiagnosed eating disorders are in our offices and hospitals; sensitive history taking can not only uncover the presence of an eating disorder but also build patient-clinician rapport toward effective treatment.

What challenges and successes have you experienced with caring for patients with eating disorders?

Friday, January 2, 2015

Can treating mild hypertension be too much medicine?

- Kenny Lin, MD, MPH

As part of a plan to improve our practice's quality of care for patients with high blood pressure, my office's nurse announces at every morning huddle which patients on that day's schedule had a blood pressure measurement of greater than 140/90 at their last visit. Most of these patients have measurements consistent with mild hypertension (systolic blood pressure less than 160 mm Hg and/or diastolic blood pressure less than 100 mm Hg). However, a previous AFP Community Blog post pointed out that the few randomized trials of anti-hypertensive medications in this population did not show improvements in cardiovascular outcomes or mortality.

In fact, some have gone as far to suggest that the identification and treatment of mild hypertension in persons at low cardiovascular risk may be "too much medicine," given the poor accuracy of office blood pressure measurements and that these patients typically receive drugs (and their accompanying side effects) rather than lifestyle change counseling. Last year's JNC 8 Guidelines for the Management of Hypertension in Adults added fuel to this controversy by acknowledging that no randomized trial evidence supports any systolic blood pressure treatment threshold in adults younger than 60 years, and recommending that adults 60 years and older receive medication only if their blood pressure is higher than 150/90.

In the first of a series of AFP editorials about overscreening, overdiagnosis, and overtreatment, Drs. Mark Ebell and Jessica Herzstein highlighted several examples of screening that does not improve patient-oriented outcomes: too-short intervals between screening colonoscopies; Pap smears in women after a hysterectomy for benign disease; and mammography in older women with dementia. Does looking for hypertension in adults without cardiovascular risk factors fall into this category as well?

new meta-analysis published in the Annals of Internal Medicine could tip the scales in favor of medicating adults with mild hypertension. Combining individual-patient data from a collaboration of blood pressure treatment trials with that from a previous Cochrane review, Dr. Johan Sundstrom and colleagues concluded that pharmacotherapy for mild hypertension reduced the relative risk of strokes, cardiovascular deaths, and total deaths by 22 to 28 percent after 5 years. (They estimated, however, that absolute risk reductions in contemporary primary care populations would be a modest 0.6 to 1.2 percent, or a number needed to treat of 83 to 167.)

Key take-home points are that the absolute benefits of treating otherwise healthy persons with mild hypertension are relatively small; lifestyle modification should generally precede medication; and blood pressure measurement should be performed and repeated carefully to ensure accurate identification of hypertensive patients. In a draft recommendation statement, the U.S. Preventive Services Task Force recently advised routine home blood pressure monitoring to confirm new hypertension diagnoses, which should hopefully limit overdiagnosis and overtreatment.

Monday, December 22, 2014

Screening for developmental dysplasia of the hip: when organizations disagree

- Jennifer Middleton, MD, MPH

If your medical education was anything like mine, chances are you learned to incorporate hip testing into every newborn exam, but the evidence base to support that common practice is uncertain. "Common Questions About Developmental Dysplasia of the Hip," an article in the December 15 issue of AFP, includes a discussion about the varied hip dysplasia screening recommendations by the United States Preventive Service Task Force (USPSTF), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and the Pediatric Orthopaedic Society of North America (POSNA).

The USPSTF gives screening for developmental dysplasia of the hip (DDH) an "I" recommendation:
There is poor evidence (poor quality studies) of the effectiveness of both surgical and non-surgical interventions; avascular necrosis of the hip (AVN) is reported in 0% to 60% of children who are treated for DDH. Thus, the USPSTF was unable to assess the balance of benefits and harms of screening for DDH but was concerned about the potential harms associated with treatment of infants identified by routine screening.
The AAFP concurs with the USPSTF:
The AAFP concludes that the evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes. 
Although the AAP agrees that the quality of available studies was low, they came to a different conclusion:
There were few controlled trials and few studies of the follow-up of infants for whom the results of newborn examinations were negative. When the evidence was poor or lacking entirely, extensive discussions among members of the committee and the expert opinion of outside consultants were used to arrive at a consensus....All newborns are to be screened by physical examination. [emphasis in original]
And, the POSNA aligns with the AAP:
The Pediatric Orthopaedic Society of North America recommends that all health care providers who are involved in the care of infants continue to follow the clinical practice guideline for early detection of developmental hip dysplasia (DDH) outlined by the American Academy of Pediatrics. 
When medical organizations' recommendations differ, family physicians can be left wondering who to follow and what to do. Considering each organization's goals and process for developing recommendations can help. The USPSTF and AAFP typically will not make a recommendation in the absence of high-quality studies, therefore setting the bar high to receive anything but an "I" (insufficient evidence) recommendation. The AAP and Pediatric Orthopaedic Society, however, are more comfortable providing a recommendation based on expert opinion and lower-quality studies.

We strive, in this age of evidence based medicine (EBM), to base our clinical decisions on high-quality evidence. When high-quality evidence is lacking, however, we must rely on what we do have to make decisions; in this case, on expert opinion and lower-quality studies. In the absence of high-quality studies, reasonable physicians may also be expected to disagree about how to interpret what is available. The practice of EBM does not seek to eliminate individual clinician judgment, and each of us is left to determine how to put into practice what evidence and expert opinion currently exists. There's an AFP By Topic on Neonatology/Newborn Issues if you'd like to read more.

What is your practice regarding screening infants for DDH?

Tuesday, December 16, 2014

What should doctors do at well-child visits?

- Kenny Lin, MD, MPH

As a family physician who provides care to children, and as a father of four ranging in age from 6 months to 8 years, I have a professional and personal interest in the content of well-child visits beyond childhood immunizations. Not only can health maintenance and counseling vary from practice to practice, previous reviews have found large gaps in the evidence to support preventive services recommended by government health agencies and medical groups. Also, clinicians who compare the Bright Futures / American Academy of Pediatrics "Recommendations for Preventive Pediatric Health Care" to the clinical recommendations for children published by the American Academy of Family Physicians (AAFP) will find that groups sometimes disagree about which services should be offered at well-child visits.

To provide perspective on how the AAFP evaluates evidence regarding the net benefit of individual preventive services in children, I recently wrote an editorial in American Family Physician that reviewed the guideline process and discussed why there is insufficient evidence to recommend screening children for autism spectrum disorders, high blood pressure, and cholesterol levels. (Note to readers: although I am a member of the Commission on the Health of the Public and Science and verified that this editorial reflects current AAFP recommendations, it should not be considered an official statement of the AAFP.) Here is the bottom line:

Time is a precious clinical resource. Clinicians who spend time delivering unproven or ineffective interventions at health maintenance visits risk “crowding out” effective services. For example, a national survey of family and internal medicine physicians regarding adult well-male examination practices found that physicians spent an average of five minutes discussing prostate-specific antigen screening, but one minute or less each on nutrition and smoking cessation counseling. Similarly, family physicians have limited time at well-child visits and therefore should prioritize preventive services that have strong evidence of net benefit.