Physician's First Watch: Archives

ACOG Releases New Cervical Screening Guidelines into Politically Charged Environment

New clinical management guidelines for cervical cytology screening advise that screening should begin at age 21, not at the age of first sexual intercourse.

The guidelines, released in the American College of Obstetricians and Gynecologists' ACOG Practice Bulletin, say the change is "based on the potential for adverse effects associated with follow-up of young women."

Initially, screening is recommended every 2 years. For women over 30 who have had three consecutive negative screenings, screening may occur at 3-year intervals. Women with certain risk factors may require more frequent screenings: those infected with HIV, the immunosuppressed, those with in utero exposure to DES, women with a history of cancer or cervical intraepithelial neoplasia.

Screening can be discontinued for most women between 65 and 70, or who have had a hysterectomy for benign indications and no history of high-grade CIN.

The guidelines also give recommendations on HPV screening.

Both the New York Times and the Washington Post report that release of the cervical screening guidelines and those on mammography within the same week was a coincidence. Both recognized that the ACOG guidelines would add fuel to the political firestorm over health care reform.

LINK(S):

ACOG Practice Bulletin (Free PDF)

New York Times story (Free)

Washington Post story (Free)

Published in Physician's First Watch November 20, 2009

'QFracture' Score Offers 10-Year Risk Prediction for Osteoporotic Fractures

A 10-year risk algorithm for osteoporotic fracture, called the QFractureScore, "shows some evidence of improved discrimination" over the World Health Organization's FRAX algorithm, according to an online BMJ report.

Researchers derived the algorithm from a cohort of some 2.4 million men and women in England and Wales and validated it against roughly 1.3 million others. The data were gathered from electronic medical records ranging over 15 years.

Significant associations with overall fracture risk among men included age, BMI, smoking status, alcohol use, rheumatoid arthritis, cardiovascular disease, type 2 diabetes, asthma, use of tricyclic antidepressants or corticosteroids, liver disease, and a history of falls. For women, additional associations included hormone replacement therapy, parental history of osteoporosis, gastrointestinal malabsorption, and menopausal symptoms.

The authors comment that no lab tests are needed, and that the necessary information is already in the patient's record or can be readily ascertained. They provide a web site (www.qfracture.org) to allow patients to measure their own risk.

LINK(S):

BMJ article (Free)

QFracture risk score calculator (Free)

Published in Physician's First Watch November 20, 2009

Talking Points: Diabetes and Obesity Most Prevalent in Southeastern U.S.

Diabetes and obesity are most prevalent in southeastern U.S. counties, MMWR reports.

CDC researchers used census and telephone survey data to estimate the prevalence of diabetes and obesity among adults in all 3141 U.S. counties in 2007. They found that the southeastern U.S. comprised the majority of counties that were in the top quintiles of diabetes prevalence (at least 10.6%) and obesity prevalence (at least 30.9%).

LINK(S):

MMWR article (Free)

Published in Physician's First Watch November 20, 2009

News from AHA 2009

This week, Journal Watch Cardiology, Journal Watch Psychiatry, and Physician's First Watch have been bringing you breaking news from the American Heart Association meeting in Orlando. Please have a look (most of the studies were presented at the meeting and published in peer-reviewed journals at the same time):

Journal Watch Cardiology summary of ARBITER 6 trial showing niacin superior to ezetimibe (Free)

Physician's First Watch ARBITER coverage (Free)

Journal Watch Cardiology summary of cangrelor study — a setback for the antiplatelet agent (Free)

Journal Watch Cardiology summary of study on right-ventricular pacing (Your Journal Watch subscription required)

Physician's First Watch coverage of study on ECG findings and cardiac death (Free)

Journal Watch Cardiology summary of study on high-dose losartan in heart failure (Your Journal Watch subscription required)

Physician's First Watch coverage of losartan study (Free)

Journal Watch Cardiology summary of study on iron for heart failure patients (Your Journal Watch subscription required)

Journal Watch Cardiology summary of study on continuous LV assistance for heart failure (Your Journal Watch subscription required)

Journal Watch Psychiatry summary of study on treating depression after CABG (Your Journal Watch subscription required)

Journal Watch Cardiology summary of study on hospital report cards and patient outcomes (Your Journal Watch subscription required)

Physician's First Watch coverage of STEMI and PCI guidelines (Free)

Published in Physician's First Watch November 19, 2009

Updated PCI And STEMI Guidelines from ACC/AHA

The American College of Cardiology and the American Heart Association have released updated guidelines on managing patients with ST-segment-elevation myocardial infarction and those undergoing percutaneous coronary intervention.

Based on studies and meta-analyses published since the 2007 update, the recommendations range from use of glycoprotein receptor antagonists to the timing of interventions in unstable angina. Among the items:

• The writing group would not make an official recommendation on the use of dual antiplatelet therapy with proton-pump inhibitors, citing a lack of published evidence. (The FDA, on Tuesday, warned that clopidogrel's efficacy can be severely affected by omeprazole.)
  
• The group reduced slightly the anticipated benefits of using insulin to control blood glucose in STEMI and recommends its use for levels above 180 mg/dL.
  

LINK(S):

Journal of the American College of Cardiology guidelines (Free)

Published in Physician's First Watch November 19, 2009

Moderate-to-High Alcohol Intake Linked to Reduced CHD Risk in Men

Men who drink moderate to very high amounts of alcohol may have a reduced risk for coronary heart disease, according to an observational study in Heart.

Over 40,000 Spanish men and women completed questionnaires about their lifestyles, including alcohol intake, and were followed for a median of 10 years. During that time, 1.5% developed CHD.

After adjustment for lifestyle factors and comorbid conditions, men who regularly consumed moderate to very high amounts of alcohol (range: 5 to at least 90 g/day — the equivalent of roughly one to six standard drinks) had about half the risk for CHD as those who never drank. Findings were similar for all kinds of beverages consumed.

Among women, alcohol intake was not significantly associated with CHD.

LINK(S):

Heart article (Free abstract; full text requires subscription)

Published in Physician's First Watch November 19, 2009

FDA Approves New Treatment for Shingles-Related Pain

The FDA has approved Qutenza, a patch containing 8% capsaicin, to treat postherpetic neuralgia.

Qutenza must be applied to the skin by a healthcare professional. It can be used for 60 minutes, as often as once every 3 months, according to the manufacturer.

Before placing a patch, providers should treat the affected area with a topical anesthetic. In addition, they should monitor patients for at least 1 hour after patch application because of the risk for increased blood pressure. Other side effects may include pain, swelling, itching, redness, and bumps at the application site.

Capsaicin, a compound in chili peppers, is available in over-the-counter products in lower concentrations, but this is the first prescription-level formulation approved by the FDA.

LINK(S):

FDA news release (Free)

Qutenza prescribing information (Free PDF)

Journal Watch General Medicine summary on capsaicin and chronic pain (Your Journal Watch registration required)

Published in Physician's First Watch November 19, 2009

FDA: Clopidogrel's Antiplatelet Effect Can Be Halved by Omeprazole

The FDA is updating clopidogrel's label to warn against its concomitant use with the proton-pump inhibitor (PPI) omeprazole. The agency says omeprazole can reduce clopidogrel's antiplatelet effect.

New manufacturer-conducted studies indicate that clopidogrel's antiplatelet effect was reduced by nearly 50% in people receiving both drugs. Administering the drugs at different times does not diminish this drug interaction, the FDA warns.

Omeprazole blocks the enzyme CYP2C19, which converts clopidogrel into an active metabolite. Other drugs that should also be avoided in tandem with clopidogrel include cimetidine, fluconazole, ketoconazole, voriconazole, etravirine, felbamate, fluoxetine, fluvoxamine, and ticlopidine. (The agency says it does not yet have enough information to make recommendations about PPIs other than omeprazole, although esomeprazole — a component of omeprazole — should also be avoided with clopidogrel.)

The FDA notes that providers should also make sure that their patients on clopidogrel are not taking over-the-counter versions of omeprazole or cimetidine.

LINK(S):

FDA letter to healthcare professionals (Free)

Clopidogrel prescribing information (Free PDF)

Journal Watch Cardiology summary of earlier study on clopidogrel and PPIs (Free)

Published in Physician's First Watch November 18, 2009

Losartan for Heart Failure: High Dose Better Than Low

The angiotensin-receptor blocker (ARB) losartan improves heart failure outcomes better when given as a high rather than low dose, according to a manufacturer-conducted, international study in Lancet.

Some 3800 patients with heart failure, reduced left ventricular ejection fractions, and intolerance to ACE inhibitors were randomized to receive 50 mg or 150 mg of losartan daily. After nearly 5 years, the incidence of the primary composite endpoint — death or admission for heart failure — was significantly lower with 150 mg than with 50 mg of losartan (43% vs. 46%).

The higher dose was associated with more hyperkalemia, hypotension, and renal impairment, although drug discontinuation rates did not differ between the groups.

The authors say their results "show the value of up-titrating ARB doses to confer clinical benefit," while noting that their findings are not generalizable to patients who can tolerate ACE inhibitors.

LINK(S):

Lancet article (Free abstract; full text requires subscription)

Lancet comment (Subscription required)

Journal Watch Cardiology summary (Your Journal Watch subscription required)

Published in Physician's First Watch November 18, 2009

High-Dose Folic Acid plus Vitamin B12 Supplements Linked to Cancer

Folic acid supplementation is associated with increased risk for cancer, according to a Norwegian study in JAMA. However, an editorial gives reassurance on the implications for the U.S.

Researchers examined cancer rates and mortality in some 6800 patients with ischemic heart disease who were randomized to receive various combinations of folic acid (0.8 mg/day), vitamin B12 (0.4 mg), or vitamin B6 (40 mg) — or placebo — for 3 years in an attempt to lower cardiovascular risks.

After a total follow-up of 6.5 years, risks for cancer diagnoses, cancer mortality, and all-cause mortality were higher in patients taking folic acid plus vitamin B12 than in those not taking the supplements (relative risk range, 1.18–1.38).

Editorialists note that cancer rates have dropped since the U.S. began fortifying grains with folic acid to prevent neural tube defects. In addition, the doses of folic acid used in the trial were about five times higher than the usual U.S. intake.

LINK(S):

JAMA article (Free abstract; full text requires subscription)

JAMA editorial (Subscription required)

Journal Watch General Medicine summary (Your Journal Watch subscription required)

Published in Physician's First Watch November 18, 2009