Update in Primary Care, Feb 2019- Part 2

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Here’s the second half of the Update in Primary Care, presented with Peter Phan at the Southern SGIM meeting in Houston, TX.

I summarized some of this evidence in a recent post on diabetes drugs- check this if you (like me) can’t keep the acronyms straight. This paper was published in JAMA in April.

This was a network meta-analysis designed to compare outcomes of SGLT-2 Inhibitors, GLP-1 Agonists, and DPP-IV Inhibitors. There were A LOT of results here, but the main takaway for me is that SGLT-2 inhibitors and GLP-1 receptor agonists have a mortality benefit in diabetics. The reduced mortality is more pronounced in SGLT-2 Inhibitors, and this class also showed significant reduction of heart failure events.

This video from JAMA provides a great overview of the study.

Switching gears, this paper compared vaginal estradiol and a fancy vaginal gel with placebo estradiol and placebo gel for patients with vulvovaginal atrophy symptoms. All patients got a vaginal tablet and a gel- either active tablet/placebo gel, active gel/placebo tablet, or dual placebo.

Women reported significant symptoms at baseline- including 50% reporting that they frequently felt distressed with sexual functioning.

Most women had improved symptoms, no matter the treatment. But it didn’t matter which treatment they got, so a cheaper OTC lubricant seems just as good as an expensive prescription for topical estradiol.

Finally, a paper about primary care workflow. There is a lot of burnout in medicine, and in primary care. One reason is the clerical burden that doctors have- entering orders, signing forms, and writing notes for billing purposes. Scribes have been proposed as a potential answer to this clerical overload.

This study gave scribes to 18 primary care physicians (IM and Family Med) in the Kaiser Permanente system. All the practices had 3 month alternating blocks of time with a scribe, and time without a scribe. They measured MD satisfaction, patient satisfaction, perceived time working in the EMR outside of work hours, and actual time in the EMR.

During their time with the scribe, MDs were much more likely to report spending <1 hour per day and <1 hour per weekend working in the electronic medical record. Patients felt that doctors were spending more time interacting with them rather than the computer. Objectively, MDs were more likely to get phone and clinic encounters done on time (perhaps important to your C-suite) and spent 77 minutes less time per half day of clinic in documentation. They actually only spent 17 minutes fewer per week logged into the EMR during off hours.

Take homes for Part 2

  • Think about SGLT-2 inhibitors and GLP-1 Inhibitors for your diabetic patients. They seem to have a mortality and cardiovascular benefit over other agents
  • Try OTC topical lubricants first for vulvovaginal atrophy symptoms.
  • Think about scribes in your primary care practice if you are feeling overwhelmed by clerical work.
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Update in Primary Care, Feb 2019

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I’m just back from the always fun Southern SGIM Annual meeting, in Houston, TX. I had the pleasure of presenting an Update in Primary Care with the great Peter Phan. It’s a great reminder of our evidence base in outpatient medicine, so wanted to share it here as well. Plus a certain Master Educator called me out in his Unknown Vignette discussion, so I heard that I might have some new followers- Welcome!

Here goes!

First up: this RCT published in October 2018 in JAMA compared PT to Arthroscopic surgery for meniscal injury. A big caveat is that patients with locking of the knee were excluded, so this likely is focused on patients with degenerative meniscal injury.

Here are the results: This was a non-inferiority trial, so a low p value means that PT was NON-INFERIOR.

There was no difference in knee function between PT and Surgery at 3, 6, 9, and 24 months. There may have been a improvement at 12 months, but it disappeared by studies end.

Next, what happens to patients with documented Penicillin Allergy? This study from June 2018 in BMJ looked at just that. This was a matched, prospective cohort study that enrolled over 300K adults.

The authors looked at risk of MRSA or C.Diff infections, and controlled for a variety of potential confounders, including: PPI, Antibiotic or steroid use, admission to SNF or hospital, and others.

Patients with a documented Penicillin allergy were 69% more likely to have MRSA and 26% more likely to have C. Diff.

Interesting side note, most patients (95%!) with a documented penicillin allergy are not, in fact, actually allergic to penicillin. So it is worth investigating- get a good history, and consider allergist evaluation even if the allergy seems legit.

Number 3, Aspirin, Aspirin, Aspirin. This has been a super hot topic this year, with lots of studies. We reviewed ASCEND in NEJM, published in October.

This study looked at diabetics on aspirin for primary prevention. This was a prospective RCT that enrolled over 15K diabetics and followed them for 7.5 years.

They were randomized to 100mg of ASA or placebo. 75% of the patients were also on statins. They evaluated a combined CV endpoint (death, MI, TIA, stroke) as well as colon cancer incidence. They also measured major bleeding events.

There was a risk reduction of first vascular event for patients on aspirin, RRR 12%, NNT 91.

However, there was also a 29% increased relative risk of major bleeding in those patients. And no change in cancer rates. So harm from ASA seems to outweigh the benefits in diabetics.

And check these other papers in NEJM: ASPIRE and ASPREE. Also showing more harm than help for aspirin in patients over 70. There is a great Curbsiders episode on this- check that out on your favorite podcast app, and see the link above for the show notes.

There is the first half! Second half coming up soon!

Diabetes Treatment Guidelines 2019

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Long time coming…

but I’m back. Will try using this site as place to collect clinical pearls and educational resources from around the internets. Up first- Diabetes.

There are many new treatments for DM, and I can’t keep the initials straight, so first up, my round-up of DM treatments.

Metformin- first line therapy along with lifestyle modification.

GLP-1 RA: end in “glutide”. These are all injectable, some now once weekly. Some have proven CVD reduction benefits. In order of CVD benefit: Liraglutide (Victoza/Saxenda), Semaglutide (Ozempic), Exanatide (Byetta/Byderon).

SGLT2i: end in “gliflozin” These also have been shown to reduce CVD events, along with heart failure and progression of CKD. Empagliflozin (Jardiance) and Canagliflozin (Invokana) are examples.

DPP-4i: “Gliptins” Work by increasing Incretin, which helps the body make insulin when needed, and decreases glucose creation in the liver. Sitagliptin (Januvia) and Saxagliptin (Onglyza) are examples.

These are the most updated Standards of Care in DM, published Jan 2019. Here are the AACE executive summary and slide decks. 

I am teaching about treatment of DM, so here are some of the most relevant figures. Smart people have also told me that there is a great app with these algorithms. Search AACE Type 2 Diabetes.

First and Second line Treatments

Adding Injectable Medicines

And because conflict is interesting, here are the ACP guidelines for DM published last year, which set off a bit of a firestorm between Internists and Endocrinologists. The main differences have to do with treatment targets. ACP recommends aiming for HbA1c between 7-8% for most patients, and even higher for patients with less than 10 years life expectancy, nursing home patients, or with other chronic diseases. They feel we should focus on limiting harms and avoiding hypoglycemia in this population.   The ADA suggests keeping HbA1c less than 7% for most patients, with tighter targets for healthier patients who are doing well with current treatment, or those with cardiovascular disease. They are OK with higher HbA1c targets (<8%) in those who have demonstrated hypoglycemia, limited life expectancy, or comorbidities.

Enjoy!!