Commentary

Jan 26, 2016

It’s time to tell your patients that mom was right. You shouldn’t believe everything you see on television. Televised medical talk shows have become a daily viewing ritual for millions around the world. The Dr Oz Show is so popular that it earned him the title “America’s Doctor”, attracting massive numbers of followers as did the show The Doctors. It is no surprise that the public is drawn to the attention-grabbing headlines and sound bites used by the media to embellish...

Comments: 0
Jan 8, 2016

With increased emphasis on disease prevention, gestational diabetes (GDM) is worthy of more attention. The incidence of GDM is on the rise not only in the United States (U.S.) but worldwide.1,2 Complications of GDM such as preeclampsia, cesarean delivery, neonatal hypoglycemia, macrosomia, and birth trauma negatively impact maternal and fetal health.  And result in a heavy economic burden. An estimated $1.3 billion — that’s billion with a “b” — was spent on GDM-associated problems...

Comments: 1
Dec 31, 2015

Several studies have evaluated the correlation between low-dose aspirin and NSAID use and the development of colorectal cancer. In 2007, the U.S. Preventive Services Task Force (USPSTF) recommended against the use aspirin for the prevention of colorectal cancer in most adults.1 However, there is mounting evidence that daily, long-term aspirin use may prevent colorectal cancer in patients aged 50-69.2 Could something as simple as an aspirin a day prevent colon...

Comments: 0
Nov 19, 2015

When deciding which medications to use to treat a patient with type 2 diabetes, there are many options after initial treatment with metformin. The selection of a second-line agent is based on many factors including efficacy, cost, adverse effects, effect on weight, comorbidities, hypoglycemia risk, and patient preference.1  No clear consensus exists.  One characteristic that would truly help differentiate agents is their effect on cardiovascular events.

 

Many...

Comments: 3
Oct 30, 2015

After a patient has a transient ischemic attack (TIA) or minor stroke, the risk of having another is alarmingly high — 10% to 20% will have another stroke within 3 months and most events occur within 2 days.1-3  Both the American Heart Association (AHA) and American College of Chest Physicians (ACCP) guidelines recommend aspirin 160-325mg within the first 48 hours of symptom onset.4-5  The CHANCE (Clopidogrel in High risk patients with Acute Non-disabling...

Comments: 0
Oct 16, 2015

The recommended treatment duration for a first episode of unprovoked venous thromboembolism (VTE) is, at a minimum, 3 months with extended anticoagulation favored for those who are not at high risk for bleeding.  However, the optimal duration of anticoagulation therapy remains unknown.1  Earlier studies have shown that an extended course of oral anticoagulation (OAC) with warfarin reduced VTE recurrence but at the expense of increased bleeding.2,3  The Prolonged...

Comments: 0
Oct 3, 2015

Many clinicians are questioning the role pharmacists should play in anticoagulation therapy management as direct oral anticoagulants (DOACs) increasingly replace warfarin for a variety of indications. When we say “anticoagulation clinic” most of us envision a group of practitioners — often pharmacists — delivering coordinated care, providing ongoing patient education, and using laboratory data to make adjustments in warfarin doses. Unlike warfarin, DOACs do not require routine laboratory...

Comments: 2
Sep 20, 2015

To treat acute asthma exacerbations in children, how about a single dose of dexamethasone and your done!  Sounds simple, easy, and convenient.  But is it too good to be true?  Early administration of systemic corticosteroids is recommended in national guidelines to treat moderate to severe asthma exacerbations and mild asthma exacerbations that do not respond completely to short-acting β-agonists.1 The recommended treatment regimen consist of oral prednisone or prednisolone, taken...

Comments: 0
Sep 5, 2015

Monoclonal antibodies (mAb) are used to treat many disorders — from cancer to age related macular degeneration. These agents consistently come with a very high price tag often costing more than $200,000 per patient per year in the United States.1 Two new mAbs, alirocumab (Praluent®) and evolocumab (Repatha®), have been approved to treat elevated cholesterol when added to maximally tolerated statin therapy in patients with familial hypercholesterolemia or history of atherosclerotic...

Comments: 1
Jul 28, 2015

Clinical practitioners have used calculators such as the Framingham Risk Score to assess the probability that a patient will develop coronary heart disease (CHD) and to guide primary prevention therapy for decades.1  In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) released an updated risk calculator which has been widely criticized and may lead to over-prescribing of cholesterol-lowering agents (namely statins), aspirin, and...

Comments: 7
Jul 24, 2015

Stroke is responsible for 1 in 19 deaths in the United States each year and is the leading cause of long-term disability — arguable an outcome worse than death.1 More than 36 billion was spent on stroke treatment and rehabilitation in 2010.  Many strategies are used for the secondary prevention of stroke, but the real impact on health and healthcare cost can only be achieve by preventing the first stroke. Of the 795,000 people who have a stroke each year, more than 75% experience...

Comments: 0
Jul 18, 2015

Every health professional takes an oath to serve patients. To fulfill this covenant, patient trust must be earned. Without trust, patients are unlikely to share sensitive, personal information, hindering our ability to provide optimal care. Gaining trust is influenced by many factors. What influence does attire have on patients’ perceptions of their healthcare providers?

 

Several studies have examined the impact of attire on patient perceptions.  One study found that children...

Comments: 7
Jul 9, 2015

The role of continuous subcutaneous insulin infusion (CSII) in Type 2 Diabetes Mellitus (T2DM) is not clearly defined.1 In patients with type 1 diabetes mellitus, CSII improves glycemic variability, lowers the risk of hypoglycemia, reduces hemoglobin A1C (A1C), and increases treatment satisfaction as well as quality of life when compared with multiple daily injections (MDI).2,3 However, studies in patients with T2DM have produced conflicting findings.4,5,6,7...

Comments: 2
Jun 17, 2015

The results of the PEGASUS-TIMI 54 (Long-Term Use of Ticagrelor in patients with Prior Myocardial Infarction) trial were presented to a capacity audience at the opening session of the March 2015 American College of Cardiology meeting.  But after hearing the much anticipated results and reading the simultaneously published manuscript we’re left wondering if PEGASUS is a landmark clinical trial or simply a trial that validates what we have known for years.1

 

To...

Comments: 0
Jun 17, 2015

The appropriate duration of dual antiplatelet therapy (DAPT) for patients following placement of a drug-eluting stent (DES) remains controversial.1 Many clinicians have pushed for prolonged DAPT — beyond 12 months — on the assumption that extended therapy reduces recurrent cardiovascular (CV) events.  However, the benefits and harms of extended DAPT therapy are unclear and many health systems won’t authorize it.  Does the Dual Antiplatelet Therapy (DAPT) study provide sufficient...

Comments: 0
May 17, 2015

Could a commonly prescribed antibiotic, when combined with a renin-angiotensin system inhibitor, lead to sudden death?  Angiotensin converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), and spironolactone are frequently used in older adults for a variety of indications.  All can potentially cause hyperkalemia.1-2 Co-trimoxazole (trimethoprim-sulfamethoxazole) is commonly prescribed for a wide range of infections.  One study found that when co-trimoxazole is...

Comments: 0
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...

Comments: 0
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)....

Comments: 0
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...

Comments: 0
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...

Comments: 0
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...

Comments: 2
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...

Comments: 1
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...

Comments: 0
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...

Comments: 1
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...

Comments: 1

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