Link Roundup: Less is more edition

I Hate Rashes is practicing restraint during this week of excess.  Cleanse your palate with these links from around the web.

I’m beginning to think that the future of medicine is to use less of it.  Here’s a great post from one of my favorite bloggers: Gaia and Snake Oil

And here’s something from the New Yorker on Prescription Opiates.  We could definitely use less of these. Who is Responsible for the Pain Pill Epidemic

Similarly, two links on insomnia that DON’T mention medicines. Just don’t read these after your turkey sandwich.  Sleep Therapy as Depression Treatment and Sleep Help Guide. The second link was mentioned in the last blog post; it’s a great patient self-help website.

Once you finish eating, check out this short commentary from the UK. Green snot does not equal a Z-pack. 

After a long weekend with your nieces and nephews, you might appreciate this.  The less is more, Babies edition. Contraception Practice Essentials. A quick, comprehensive guide for diagnosis and treatment. (requires Medscape Subscription)
Check this HILARIOUS patient education website for contraception in the real world. bedsider.org.

Finally, after the third helping of sweet potato pie, some more perspective on lipid guidelines.  The Statinization of America.  Dr. Centor’s (and here)and Dr. Shaneyfelt’s take on the risk calculator in the new ACC/AHA guidelines.

Happy Thanksgivukkah Everyone!

 

Statins in the water

You might have heard about new cholesterol screening and treatment guidelines released this week.  I had 3 patients ask me about it during a single clinic session, and would have been clueless if it hadn’t been for a very smart Facebook friend.  Social media at work..

Here’s the skinny on the new guidelines.

 

  • it is risk for heart disease that is important, not so much an LDL target.  Four major groups are deemed high enough risk to warrant treatment
  • Use statins.  High potency ones like atorvastatin or rosuvastatin for higher risk patients, lower potency (pravastatin) for lower risk patients.
  • If you are going to use it, put people on a good dose and leave them there.  Really no need to check lipids every year.
  • The four groups to consider treating
    1. Known atherosclerotic cardiovascular disease: less than 75, use high potency statin; >75 use moderate potentcy statin
    2. LDL >190: high intensity statin
    3. Diabetic: moderate potency statin, use higher potency if they otherwise are high risk
    4. 10 year risk of atherosclerotic CV disease >7.5%: use moderate or high potency statin

 

The risk calculator to find out if your patient fits into that last group is here.  It is a little cumbersome to use, but is NOT the same as the Framingham or Reynolds Risk calculators that you may be used to. This might be a good thing, as the “pooled cohort” risk calculator was validated in White and African American men and women, which is somewhere that Framingham falls short.

So that’s the overview.  There are lots of questions about these guidelines that I haven’t delved into here.  It really represents a major shift in our thinking about cholesterol, which may be a good thing. It remains to be seen if our performance targets will change based on these recommendations. It follow that if our patients are on appropriate doses of high potency statins and the LDL is >100 or >70, or whatever your target may be, they may still be getting the benefit from statins.  Adding more drugs just to lower the number may not do anything for their overall risk of heart disease or stroke.

Smarter people than I have had some good things to say about the guidelines. I suggest you take a look at NY time op eds and Dr. Centor’s take- both below.  macstatin31

A case for exercise, continued

So…. the whole commenting thing didn’t work out so well.  I choose to believe that many tried and failed, rather than that I’m talking to myself over here.   So, here’s my take on our case.  Disagree? Something to add?  Speak up on Twitter (follow @ihaterashes)

 Our case..

You have a 58 year old white male patient who you’ve seen 4-5 times in your continuity clinic.  He has diabetes (uncontrolled, with HbA1c 9.5%), HTN (typically reads low 150s/90s in clinic), and hyperlipidemia (guess what?  He refuses medicines).  Oh, and his BMI is 36.

You’ve been harping on the miraculous benefits of diet and exercise all this time, and he’s finally decided to give it a try. He tells you that he’s joined Crossfit and is ready to start exercising, once you give the OK.

Does he need some testing before you give the “OK”?  The commercials say, “Talk to your doctor before starting an exercise program.”  So what are we supposed to say or do?

For low/average risk patients there is no benefit to screening for asymptomatic coronary disease. The ACC has added stress testing in asymptomatic individuals to their list of tests to avoid in the ABIM’s Choosing Wisely Initiative. 

But our patient has diabetes, so he’s not low risk.  Not only that, but he has uncontrolled hypertension and hyperlipidemia, so he most certainly has as much risk for a cardiac event as someone who has had an MI.   In fact, if you follow the Choosing Wisely link above, you note there is a caveat for patients with diabetes over age 40.  So, should we screen him?

Some guideline writers, including the American College of Cardiology, recommend stress testing in asymptomatic diabetics over 40.   The ADA says that EKG exercise testing may be indicated for those diabetics starting an exercise program if: they are over 40, over 30 with signs of advanced diabetes (nephropathy, retinopathy), smokers, or have renal failure due to their diabetes.  

So the guideline writers would screen our patient.  Here’s my concern though, what are we going to do with the information?  He already needs aggressive medical therapy (which he’s not really getting). Perhaps we would do best to just focus on that. Should we revascularize if significant ischemia is found?  

There was one trial, DIAD, which randomized 1123 asymptomatic diabetic patients to screening with adenosine MIBI vs no screening. These patients were largely well controlled with aggressive medical management, and the overall cardiac event rate was only 3% for the whole group. There was no difference in the screened and unscreened groups, however, our patient is so uncontrolled on all risk factors, I’m not sure he fits in.  Our pre-test probability of coronary disease is likely higher than 3%, even without symptoms. 

What about the exercise itself?  I’ve not done CrossFit myself, but it looks fairly intense, with a lot of callisthenic type exercises done fast enough to get an aerobic benefit.  I would be afraid that if he jumped right into an intense “boot camp” like experience like CrossFit, that he might injure himself and then quit exercise all together. It is a tricky thing to encourage exercise, but in such a way that it is more likely to stick as a lifestyle change, rather than a month or so of intermittent involvement that quickly fades away.   

So, I would probably applaud him for his initiative, but ask him to take it a little easy and work on a simple paced exercise program to start.  I would ask a lot of questions to convince myself that he really is asymptomatic, and have a very low threshold for getting stress testing (ideally with exercise MIBI).  You could refer him to cardiopulmonary rehab, so that he could get close monitoring of his HR and BP during exercise (assuming he could pay for it- insurance likely will not).  At the same time, he needs to get his risk factors under control– start a statin, titrate his HTN and diabetic medicines. Certainly give him clear warnings of angina or even anginal equivalents that he might experience, with direction to stop if he does.

Thanks to all for the patience with my blog issues.  New site is coming soon, hopefully with fewer technical difficulties!