Sunday, May 18, 2014

Primary Care Updates from SGIM!

As a primary care doctor, I can say it takes a lot of time to stay updated on the world of internal medicine.  Fortunately, many annual conferences feature " update talks," which showcase the most recent and significant studies in internal medicine.  For those of you that may have missed the Society for General Internal Medicine conference (SGIM), here are some of my key take-home pearly from various update talks.  Of course, I encourage providers to look up the original source material for additional information.   

Updates in Primary Care (lecture & slides courtesy of Drs. Amber Pincavage, Elizabeth Schulwolf, Diane Altkorn, Sachin Shah, and Scott Stern) - Clinical Pearls:
  • Supplemental Omega-3 Fatty Acids did not Prevent Cardiovascular Events in High-Risk Individuals: a randomized, double-blind placebo-controlled trial of >12 thousand patients at high risk of cardiovascular disease (85% HTN, 60% DM, 21% smokers) were randomized to 1g of fatty acids or placebo and followed for 5 years.  There was no difference in the composite endpoint of time to death from CV causes or hospital admission related to CV causes.
  • Factor 10a Inhibitors are Well-Established for Use in Atrial Fibrillation: in March, 2014, JAMA reviewed 10 RCTs of patients with atrial fibrillation, 80% of whom were taking apixaban (Eliquis) or rivaroxaban (Xarelto).  The factor 10a inhbitors are associated with a decreased risk of stroke and emboli and fewer major bleeding events.
  • The Direct Thrombin Inhibitor, Dabigatran, was NOT Efficacious in Patients with Mechanical Heart Valves: the RE-ALIGN study, published in the NEJM in 2013, was stopped early because of adverse events associated with dabigatrian (Pradaxa) (increased bleeding & thromboembolism).
  • The Factor 10a Inhibitors (rivaroxaban or Xarelto; apixaban or Eliquis; edoxaban or Lixiana) and the direct thrombin inhibitor dabigatran (Pradaxa) are non-inferior to low-molecular weight heparin or vitamin K antagonists for prevention of venous thrombo-embolism recurrence.  Apixaban and edoxaban were associated with decreased bleeding; there was no difference with rivaroxaban. There was no difference in major bleeding with dabigatran.
  • Women with Moderate-Severe Stress Incontinence May Benefit from Immediate Surgical Referral: NEJM study from 2013 (Labrie et al) analyzed 460 women with stress incontinence (8 episodes/day; 65% premonopausal) treated with either surgery (mid-urethral sling) or physiotherapy and looked out subjective improvement at 12 months.  While about half of patients in the physiotherapy arm crossed over to the surgery group, the intention-to-treat analysis showed that subjective improvement was found in 90% of patients in the surgery group versus 64% in the physiotherapy group. Of note, all the adverse events were among women that had surgery (~9.8% of women --> ~3% bladder perforation, ~4% vaginal epithelial perforation, ~3% reoperation).
  •  Varenicline Plus Bupropion Achieved Improved Tobacco Quit Rates: JAMA 2014 article comparing open label varenicline (Chantix) plus bupropion SR or placebo for 12 weeks (obs until 52 weeks) in smokers highly motivated to quit.  The combination of varenicline and bupropion was associated with superior quit rates at 12 and 26 weeks, but not 52 weeks.  Looking specifically at heavy smokers (>20 cigarettes/day), the combination was superior at 26 and 52 weeks (33 v. 18%; NNT=6).  There were more psychiatric symptoms in the combination group (anxiety 7 v. 3%; depression 3 v. 0.8%)
  • Short-term Steroids were Equivalent to Longer Courses of Steroids for COPD Exacerbations: this was a randomized controlled trial of primarily hospitalized patients with a COPD exacerbation given methylprednisolone 40mg IV, then prednisone 40mg daily for 5 days versus 14 days.  There was no difference in the primary outcome of frequency or time to re-exacerbation, and the shorter course of steroid was associated with a shorter length of stay.
  • Surgical Treatment versus Physical Therapy for Osteoarthritis Patients with a Symptomatic Meniscal Tear: this was a non-blinded trial of arthroscopic surgery or physical therapy for patients with a meniscal tear on imaging. The majority of patients were excluded from the trial (exclusion criteria: chronic locked knee, grade 4 OA, chondrocalcinosis, bilateral tears, prior knee surgery), and there was a high cross-over rate (30%). The primary outcome was a physical function score at 6 months and there was no difference found between groups; similarly a pain score was not different.  The clinical take-home point was that there was no clear benefit to immediate surgery so it is reasonable to reserve this therapy for the estimated 1/3 of patients that will not improve with PT.

Updates in Hepatology (lecture & slides courtesy of Drs. Shelly-Ann FLuker, Lesley Miller, Anne Spaulding, and Barbara Turner) - Clinical Pearls:
  •  For the Moment, the Recommended Treatment for Genotype 1 HCV Infection Consists of Peginterferon + Ribavirisn +Sofosbuvir for 12 weeks: the NEUTRINO trial (NEJM 2013) was an open-label, single arm study of sofosbuvir, peginterferon, and ribaviring for 12 weeks in treatment-naive patients and showed a sustained virological response of 92% at 12 weeks in non-cirrhotics, and 80% in cirrhotics (17% of the sample).
  •  For the Moment, the Recommended Treatment for Genotypes 2 and 3 is Ribavirin and Sofosbuvir for 12 to 24 weeks: the FISSION trial compared sofosbuvir+ribavirin to peginterferon+ribavirin for 24 weeks in patients with genotypes 2 and 3 and the former was associated with improved sustained virologic response at 12 weeks (98% in genotype 2 without cirrhosis, 91% geno 2 with cirrhosis; 61% geno 3 no cirrhosis, 34% geno 3 with cirrhosis).
  • For the Moment, the Recommended Treatment for Genotype 1 HCV, Treatment-Experienced Patients is Sofosbuvir + Simepravir for 12 weeks: based on the COSMOS trial showing superior outcomes for treatment experienced patients and cirrhotic patients.

After this, I will post updates from the Diabetes and Womens' Health Talks! 

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