Medical Perspectives | Others

February 20, 2020



John V. Jiao, MD

The path to being a doctor is not an easy task. It takes a lot of hard work, dedication, persistence, sacrifice and plenty of sleepless nights just to obtain the coveted M.D. title. After graduating from medical school, passing the board exam, and obtaining the license to practice, all start at the same level, as a primary care physician. Some opt to go into further specialization or residency to hone their skills and craft while others choose to continue as primary care physicians. Being a primary care physician is no simple task either; they are at the forefront of medical care in triaging, diagnosing, and treating patients. The broad scope of their practice can make it hard for them to be updated to the recent advancements in medicine.

 

In the recent years, there has been an increasing number of research studies published in various media, whether it be online publications, magazine articles, or even through research conventions. This is probably due to the modernization and fast paced advancements in medicine and technology.

 

For more than 20 years, a group of expertsin family medicine, pharmacology, hospital medicine, women’s health, and evidence-based medicine has systematically reviewed more than 110 research journals to identify the most likely to change in primary care practice.  Their goal is to identify those patient-oriented evidences that matters such as improvement in symptoms, morbidity, or mortality, and can recommend a change in the modern practices of many physicians. They have evaluated and listed the top clinical topics that Primary Care Physicians encounter in their day-to-day practices.

 

First is Cardiovascular Diseases and Hypertension. Here in the Philippines, it is one of the leading causesof morbidity and mortality. In determining if a patient has this disease, the physician must be able to obtain the blood pressure accurately.  Below are the recent evidence-based findings that were collated in different studies.

 

  • Get the patient’s blood pressure using a completely bare arm to get the most accurate measurement. Let patients relax for a few minutes, and then measure their blood pressure. A difference of 4 mm Hg systolic and 6 to 7 mm Hg diastolic reading matter especially when deciding whether to add a second or third antihypertensive.
  • Let patients rest and consider using an average of several automated cuff measures. In a Dutch study, monitoring blood pressure readings in the office for 30 minutes resulted in markedly lower readings compared with the last office reading (approximately 23/12 mm Hg lower). The clinicians report they would be much less likely to intensify treatment if they used these readings.
  • In older patients, targeting 120/80 mm Hg has benefits but also increases the risk of renal dysfunction. In this post-hoc analysis of the previously published Systolic Blood Pressure Intervention Trial (SPRINT), lowering the systolic blood pressure of patients who are at increased risk of cardiovascular events (average age = 68 years) will decrease their risk of CVD but increase their likelihood of developing moderate renal dysfunction. It will not, at least over three years, increase their likelihood of developing end-stage renal disease.
  • Measure blood pressure after the patient has been standing for one minute and not three minutes. Finding an orthostatic drop within the first minute after standing more accurately predicts dizziness and future adverse events than finding it at the currently recommended three minutes.
  • There is no clear evidence of benefit for treating hyperlipidemia in olderpatients, especially in those older than 75 years. If a patient makes it to 65 years of age without developing CVD, lowering his or her cholesterol level at this point is not effective, and might even be harmful if treatment is started at 75 years of age. Given the lack of benefit also shown in other studies, it might be time to stop checking and treating high cholesterol in these age groups.
  • Routine home glucose monitoring is not needed for patients with type 2 diabetes not taking insulin. Home glucose monitoring of patients in primary care does not improve A1C levels or quality of life over one year in those who are not taking insulin. Patients did not feel more empowered or satisfied as a result of home monitoring, nor did they have fewer hypoglycemic episodes.
  • Cardiovascular mortality increases with intensive blood sugar control for diabetes. The initial Action to Control Cardiovascular Risk in Diabetes (ACCORD) study, which compared standard treatment (A1C target of 7.0% to 7.9%) with intensive control (A1C target of 6.0%), found that, despite good intentions, cardiovascular and overall mortality are significantly higher when blood glucose levels are lower. This study, which followed patients for an additional five years, found that patients in the intensive treatment group continued to keep their A1C levels lower than in the standard care group; however, they also continued to be at increased risk of death from a cardiovascular event.
  • Screening for prediabetes with fasting blood sugar or A1C levels is inaccurate. In this analysis, an elevated A1C or fasting plasma glucose level only sometimes lines up with impaired glucose tolerance testing results. If we take an abnormal two-hour glucose tolerance test result to be the true harbinger of eventual type 2 diabetes, an elevated A1C level is neither sensitive nor specific, and a fasting glucose level is specific (can accurately rule in risk) but not sensitive. Depending on the screening test you use, many patients will receive an incorrect diagnosis, whereas others will be falsely reassured.
  • Gabapentinoids are ineffective for patients with chronic low back pain. The existing data on gabapentinoids for chronic low back pain are limited in number and quality. The amount of pain reduction is low to moderate, whereas the rate of adverse effects is high. The few studies that assessed function found no improvement.
  • Pregabalin is not effective for patients with acute or chronic sciatica. A study included in the systematic review randomized 207 patients with moderate to severe sciatica and followed them for one year. The authors concluded that pregabalin does not relieve pain, improve function, or improve any other outcomes in patients with sciatica
  • Physical therapy is not helpful for acute ankle sprain. Physical therapy (up to seven sessions) does not hasten resolution of symptoms or improve function in adults with ankle sprain. Approximately 60% of patients who receive usual care or physical therapy do achieve excellent resolution. Sending patients home with the usual RICES protocol: rest, ice, compression, elevation, and splinting is still one of the most effective management of ankle sprain.
  • Corticosteroid injections do not improve outcomes for knee osteoarthritis and may be harmful. This study found that regular three-month intra-articular injections of triamcinolone for two years resulted in no significant difference in pain and function assessments compared with normal saline solution. However, a significant increase in cartilage loss and damage occurred in patients receiving corticosteroids compared with saline.
  • There is little, if any, difference in safety among celecoxib, ibuprofen, and naproxen. The differences among the drugs are mostly very small and there is no difference among them for the most important outcomes (death from any cause, cardiovascular death, and stroke). If you choose to recommend celecoxib over less expensive drugs such as naproxen or ibuprofen, prescribe the generic version, which is much less expensive, and do not prescribe more than 200 mg daily.

Another one of the leading morbidity and mortality that has a high complication rates with a very close relation to hypertension and cardiovascular diseases is diabetes mellitus. The review primarily addressed the management of Type 2 Diabetes.

The next topic reviewed and addressed by this study was musculoskeletal disease. This is one of the most common complaints encountered in primary care. This is most common among those who do strenuous physical work, those who are involved in accidents, or those who are already experiencing the signs of aging.

These are just some of the topics addressed that were reviewed and discussed.  Due to the sheer volume of different studies and guidelines being published, with variations due to age, sex, race, country, region, it would still be up to the physician to discern what is best for his/her patient. Some of the reviews might not be applicable to certain patients while others might be more beneficial compared to the current guidelines. Ultimately, it is our job as healers to adhere to our oath of “Do No Harm” and do what is best not just for our patient but also for the advancement of our profession.

 

References:

  • ACCORD Study Group. Nine-year effects of 3.7 years of intensive glycemic control on cardiovascular outcomes. Diabetes Care. 2016; 39(5): 701-708.
  • Barry E, Roberts S, Oke J, Vijayaraghavan S, Normansell R, Greenhalgh T. Efficacy and effectiveness of screen and treat policies in prevention of type 2 diabetes: systematic review and meta-analysis of screening tests and interventions. BMJ. 2017; 356: i6538.
  • Beddhu S, Rocco MV, Toto R, et al.; SPRINT Research Group. Effects of intensive systolic blood pressure control on kidney and cardiovascular outcomes in persons without kidney disease: a secondary analysis of a randomized trial. Ann Intern Med. 2017; 167(6): 375-383.
  • Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Statin use for the primary prevention of cardiovascular disease in adults. US Preventive Services Task Force recommendation statement. JAMA. 2016; 316(19): 1997-2007.
  • Bos MJ, Buis S. Thirty-minute office blood pressure monitoring in primary care. Ann Fam Med. 2017; 15(2): 120-123.
  • Brison RJ, Day AG, Pelland L, et al. Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial. BMJ. 2016; 355: i5650.
  • Ebell MH, Grad R. Top 20 research studies of 2017 for primary care physicians. Am Fam Physician. 2018 Volume 97, Number 9, Published May 1, 2018, Accessed at www.afp.org/afp
  • Han BH, Sutin D, Williamson JD, et al.; ALLHAT Collaborative Research Group. Effect of statin treatment vs usual care on primary cardiovascular prevention among older adults. The ALLHAT-LLT randomized clinical  trial. JAMA Intern Med. 2017; 177(7): 955-965.
  • Jüni P, Hari R, Rutjes AW, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. 2015; (10): CD005328.
  • Juraschek SP, Daya N, Rawlings AM, et al. Association of history of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults. JAMA Intern Med. 2017; 177(9): 1316-1323.
  • Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. N Engl J Med. 2017; 376(12): 1111-1120.
  • McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017; 317(19): 1967-1975.
  • Nissen SE, Yeomans ND, Solomon DH, et al.; PRECISION Trial Investigators. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016; 375(26): 2519-2529.
  • Ozone S, Shaku F, Sato M, Takayashiki A, Tsutsumi M, Maeno T. Comparison of blood pressure measurements on the bare arm, over a sleeve and over a rolled-up sleeve in the elderly. Fam Pract. 2016; 33(5): 517-522.
  • Qaseem A, Barry MJ, Humphrey LL, Forciea MA. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline update from the American College of Physicians. Ann Intern Med. 2017; 166(4): 279-290.
  • Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017; 166(6): 430-437.
  • Shanthanna H, Gilron I, Rajarathinam M, et al. Benefits and safety of gabapentinoids in chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2017; 14(8): e1002369.
  • Young LA, Buse JB, Weaver MA, et al.; Monitor Trial Group. Glucose self-monitoring in non-insulin-treated patients with type 2 diabetes in primary care settings: a randomized trial. JAMA Intern Med. 2017; 177(7): 920-929.


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