Commentary

May 4, 2015

We all have an innate desire for clarity in our decisions. Often, however, we are faced with controversy and uncertainty.  Grey areas where there is a gap between clinical practice, logical reasoning, and evidence.  One of these grey areas is the “right” approach to the peri-procedural management of chronic anticoagulation.  There are so many clinical decisions involved (See Table 1) and little clarity about any of them!

 

Table 1:  Clinical questions regarding...

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Apr 20, 2015

In an age when expensive biologic agents get all of the attention, could adding something as simple and inexpensive as fish oil to disease-modifying anti-rheumatic drugs (DMARDs) in patients with rheumatoid arthritis make a difference?  Could it delay the progression to more intensive, expensive, and risky therapies?

A number of studies using fish oil have shown it can reduce the number of tender joints and duration of morning stiffness in patients with rheumatoid arthritis (RA)....

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Mar 30, 2015

To some, “home-based primary care” (HBPC) may evoke images of frail shut ins — unable to leave their homes due to physical, mental, or cognitive impairments.  Others imagine a nostalgic past when physicians made house calls to acutely ill patients. The aging of America is no secret.1 With aging, comes an increased burden of disease and pharmacotherapy.2 Those with multiple chronic conditions are high utilizers of health care resources.3-5  A small number of...

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Mar 9, 2015

Can deploying trained laypeople working directly with low income adults with asthma in the community improve outcomes? This is what the Home-Based Asthma Support and Education (HomeBASE) trial set out to answer.1 While comprehensive evidence-based guidelines and effective pharmacotherapies exist, there are still 3,345 asthma-associated deaths and 1.8 million emergency department (ED) visits each year.2,3 There is clearly a disconnect between optimal asthma therapy and...

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Feb 16, 2015

Current cholesterol guidelines promote the use of statins as first line therapy in primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) events. Despite the impressive risk reduction associated with statins, a 60% to 80% residual risk of vascular events remains. Does adding niacin to statin treatment reduce residual risk?  Or does statin therapy alone offer optimal benefit?

 

Primary prevention trials of statins have shown they can...

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Feb 12, 2015

The treatment options for type 2 diabetes mellitus (T2DM) have increased dramatically over the past decade. Despite these advancements, treatment recommendations remain largely unchanged. The American Diabetes Association (ADA) recommends that patients newly diagnosed with T2DM modify their diet, exercise, and take oral medication (i.e. metformin).  Only later should injectable therapies be considered. Until recently, the ADA’s treatment algorithm recommended basal-bolus insulin strategies...

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Jan 27, 2015

The American Heart Association reports that 1 out of 3 adults in the Unites States have high blood pressure and the direct and indirect costs exceeded $50 billion in 2009.  Clearly we need to develop a variety of approaches to manage hypertension.  It is far too common and costly for our health system.1,2 Self-monitoring of blood pressure (SMBP) has been widely used as a tool to evaluate patients with hypertension.1 While the 2014 Evidence-Based Guideline for the...

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Jan 6, 2015

Digoxin is FDA-approved for the treatment of mild to moderate heart failure (HF) as well as the control of resting ventricular rate in adult patients with chronic atrial fibrillation (AF).1 Current guidelines recommend digoxin to control resting heart rate in patients with AF when they have concurrent HF.2 But does digoxin improve outcomes in patients with AF? The available data are conflicting and observational.3-6 Does the recently published TREAT-AF (The...

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Nov 23, 2014

Heart failure not only causes disability and death but also millions of hospitalizations each year.1  The standard of care for patients with heart failure with reduced ejection fraction (HFrEF) includes a cocktail of drugs comprising an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) plus a beta-blocker and, in many cases, an aldosterone antagonist.1  The angiotensin receptor-neprilysin inhibitors (ARNIs) are a new class of drugs...

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Nov 4, 2014

Have you ever had difficulty convincing some of your patients that generic medications work just as well as their brand-name counterparts?  While there is little evidence to suggest that generic medications aren’t therapeutically equivalent, a more subtle and perhaps more vexing problem is now emerging.  From a health policy standpoint, generic medications are critically important because they are the driving force that makes the pharmaceutical marketplace more competitive.  Generic...

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Oct 8, 2014

Telecare — providing care to patients using a variety of communication technologies — has been touted as a win-win strategy for providers and patients that improves clinical outcomes at a lower cost. Systematic reviews have documented the benefits of telecare in several populations including patients with pulmonary disease, diabetes, heart disease, and hypertension.1-4  Like other chronic illnesses, chronic musculoskeletal pain is common, difficult to manage, and costly. According...

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Sep 24, 2014

Your patients with diabetes may have heard through the grapevine about resveratrol to control blood sugar.  Indeed, a recent meta-analysis concluded that dietary supplements containing resveratrol significantly lowers blood glucose, A1c, and improves insulin sensitivity in patients with diabetes.1  Dietary supplements are widely available and patients spend more than 30 billion (that’s billion with a “b”) dollars on them every year.  Health professionals should be prepared to...

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Jul 17, 2014

Several foods appear to have a positive impact on blood pressure: dark chocolate, guava fruit, soy, and garlic, to name a few.1-6  They please both the palate and the prescriber.  Most people won’t turn down chocolate and most clinicians won’t turn down the chance to lower blood pressure in a patient with hypertension.  Enter flaxseed (Linum usitatissimum L) — it’s high-fiber, rich in alpha-linolenic acid (ALA), and may be beneficial for a variety of cardiovascular...

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Jun 8, 2014

According to the Centers for Disease Control, the percentage of children diagnosed with attention deficit hyperactivity disorder (ADHD) has risen significantly from 7.8% in 2003 to 9.5% in 2007 and 11% in 2011.1 Could a common over-the-counter medication be to blame?  Acetaminophen is used by more than 50% of pregnant women in the United States for pain during pregnancy and is considered the first-line drug of choice.2 Historically it is regarded as safe, although a...

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May 1, 2014

Should we use a GLP-1 receptor agonist (GLP-1RA) rather than basal insulin in patients with type 2 diabetes whose glycemic control are falling short on oral agents alone? Metformin is strongly recommended as initial therapy by both the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE).1,2  But most patients will require more than one agent to get to goal. The 2013 AACE guidelines suggest using a GLP-1RA as initial add-on therapy in...

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Apr 3, 2014

Alzheimer Dementia (AD) is devastating and we need to start thinking outside the box with regard to treatment options. Currently available medications have only modest symptomatic benefits.1 Could something as widely available as vitamin E significantly alter the course of cognitive and functional decline invariable caused by AD?

Acheylcholinesterase inhibitors (AChEIs) are approved for use in patients in all stages of AD, while the NMDA-receptor antagonist...

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Mar 14, 2014

After publication of the Women’s Health Initiative (WHI) in 2002, postmenopausal women have often been discouraged from using hormone therapy (HT) due to concerns regarding thromboembolic disease, cancer, and cardiovascular events.  But results from a recent study suggest that HT isn’t as bad as you may think.  When HT is initiated shortly after menopause, it may actually improve cardiovascular outcomes and have no impact on cancer risk.1  Is it possible that we were wrong all...

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Feb 26, 2014

A simple fecal sample may be able to predict your patient’s risk for developing type 2 diabetes.  That’s right, not a blood test, but a STOOL test.   Our microbiome, the ecological community of microorganisms that share our bodies, influence our risk for disease.  And not just irritable bowel syndrome but many other diseases including type 2 diabetes, depression, cancer, asthma, psoriasis, and autism.1  Research regarding the connections between our microbiome and disease...

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Feb 5, 2014

In the United States, nearly 70% of adults are overweight or obese.1  Excess adipose tissue increases the likelihood of developing sleep apnea, type 2 diabetes mellitus (T2DM), dyslipidemia, and hypertension. The rate of all-cause mortality in obese individuals is higher when compared to normal weight individuals.2 Its imperative that we address body weight with all patients in all health care settings – but particularly in primary care settings.

The 2013...

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Dec 18, 2013

As baby boomers age, meeting their primary care needs will become increasingly difficult due to a diminishing number of physicians entering primary care practice, the increasing complexity of available diagnostic tools and treatments, and expanded access to care under the Patient Protection and Affordable Care Act. This perfect storm has led to calls for changes in the way primary care is delivered including the adoption of interprofessional collaboration (IPC) practice models.1...

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Dec 6, 2013

We’ve all encountered patients who’ve had difficulty taking their medications as prescribed.  Many of our patients don’t achieve the recommended treatment goals or derive much benefit their medications.  There are many reasons why patients don’t take their medications in an ideal manner — including cost barriers, unpleasant side effects, treatment complexity, and forgetfulness.  

Pharmacists are often the health care professionals charged with improving medication...

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Nov 24, 2013

The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails.”  - William Arthur Ward.

After a decade of waiting, new treatment guidelines on the management of cholesterol in adults were published on November 12, 2013.1,2,3 These guidelines depart quite significantly from previous recommendations and have already generated some controversy. Here are the top ten things every clinician should know and do.

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Sep 29, 2013

A 65 year old patient presents to your clinic with an A1C of 7.2%, a blood pressure of 146/80 mmHg and a LDL cholesterol of 103 mg/dL. Should you order a BNP level to determine the patient’s risk of developing heart failure?

Brain-type natriuretic peptide (BNP) is a biomarker which has an established role in the diagnosis of heart failure (HF).1 It is released by the cardiomyocytes in response to volume overload and myocardial stretch. The ACCF/AHA guidelines state that BNP...

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Sep 14, 2013

The recently published Look AHEAD trial found intensive lifestyle interventions had no benefit on cardiovascular (CV) morbidity and mortality in patients with diabetes mellitus (DM).  Could the results possibly be valid?  Should we stop emphasizing diet and exercise? In patients with DM, CV disease is the leading cause of morbidity and mortality.  Preventing CV disease has been traditionally accomplished by addressing modifiable risk factors and encouraging weight loss through lifestyle...

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Jun 21, 2013

When estimating a patient's renal function to determine an appropriate medication dose, many clinicians turn to the Cockcroft-Gault (CG) equation. But is this equation the best method to quickly assess and characterize renal function?   Several studies have compared various methods to predict renal function.1,2,3  The most accurate way to measure creatinine clearance (CrCl) requires a 24-hour urine collection; however this method is not routinely used in clinical practice because...

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