Update in Primary Care, Feb 2019

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!

Minimally Disruptive Medicine

So, this is a thing…

Also known as “Goldilocks” care, proponents of Minimally Disruptive Medicine aim to line up medical interventions with patient’s own goals, so as not to offer duplicate or confusing treatments.

we paradoxically add more and more to the work of being a patient when the patient is least able to manage that work.

There is a lot of discussion about the “workload” of being a patient with chronic illness, and the “capacity” to manage that workload.  We add to the workload with medicines, dietary restrictions,  multiple specialty visits. The capacity to deal with that is diminished by the illness itself so we paradoxically add more and more to the work of being a patient when the patient is least able to manage that work.

Minimally disruptive care tries to match workload and capacity. There are four principles at work (from BMJ 2009)

  • Establish the weight of burden: ideally with some set of tools or metrics that could help us define and follow this.
  • coordinate care: rather than reimbursement targeted to “one size fits all” HbA1c or LDL targets, actually use incentives to prioritize care and help patients navigate the health system
  • Acknowledge comorbidity in clinical evidence: develop guidelines that deal explicitly with managing multiple chronic conditions. Help us figure out what to prioritize for the typical veteran with DM, CAD, and COPD.
  • Prioritize from the patient perspective: the patient should be equally invested in which conditions to go after next, based on their own goals and the treatment burden. We do this already when we hold off on starting insulin (a treatment with a relatively high workload) and focus on blood pressure instead.

I came across this info via twitter and this you tube video (also below), and I like the concept. Some have called it Geriatrics for the Young, or Palliative care for those far from the end of life.   Read more here or here.

What do you think?

Drops of Jupiter

CRP: not just for osteomyelitis any more

Ever have a patient ask you about something they saw on Dr. Oz?

It says right there, it’s all about me!  What agenda could there possibly be?

This post comes from something that has gotten a good deal of media attention, but not so much attention in our training programs.  Here’s my take on high resolution CRP.

So high resolution CRP is NOT the same test that you might order on someone with a FUO or chronic infection. The typical CRP assay that you might order in that situation doesn’t do a great job at distinguishing low levels. The values on the order of 1-3mg/mL is what becomes important in coronary disease.

Several observational studies have demonstrated that there is a relationship between CRP and coronary disease, that persists when adjusting for other traditional CV risk factors. The OR for the various studies are 1.4-1.9, meaning those with higher CRP levels have 40-90% relative risk of developing coronary disease compared to those with lower CRP levels.  There have been at least 2 other large observational studies which didn’t show much incremental change in risk stratification above more traditional cardiovascular risk factors.

Another issue with CRP is what is “normal.”  Typically patients are stratified into three groups:

low risk <1.0
intermediate risk 1-3
high risk >3

Levels higher than 10 are generally due to infectious or inflammatory states and shouldn’t be used to risk stratify anyone.

How to use the hr-CRP is hotly debated, and as usual, depends on who you ask.  Some cardiology societies recommend that we check CRP on everyone at the same time you check a lipid profile. Others recommend using it more for the intermediate risk patient- those with a Framingham risk score in the 10-20% range and already at their cholesterol goal without medicine.  I find this more helpful as it may actually change management.

So speaking of management, what do you do if you check the CRP and it is high?  It can be lowered with the typical lifestyle modifications:  Mediterranean diet, exercise, stop smoking. Medicines may also help- TZDs, ACE-I/ARBs, and Statins can all lower the CRP.

The JUPITER trial studied patients with normal LDL and CRP of >2– they were randomized to Rosuvastatin vs Placebo.  The trial was stopped early for benefit in the Rosuvastatin arm– OR for the primary endpoint of MI, Stroke, Revascularization, and Death was 0.77.  NNT for the composite outcome was 169.

Unfortunately, the risk of diabetes also increased in the patients on rosuvastatin.  NNH was 167 (hmm, awfully close to the NNT). So, the jury is out on the risk/benefit here, and you should talk with your patients about the potential for both before treating them.

Other statin studies have been done for primary prevention, with positive results, but nothing as great as the magnitude of JUPITER, despite the fact that JUPITER enrolled lower risk patients. Maybe this is because Rosuvastatin is a more potent statin (lovastatin and pravastatin were in the other big trials), or maybe it’s because they stopped the trial early.  Our favorite EBM guru would remind us that trials stopped early are more likely to overestimate benefit. Here is another takedown of the trial, pointing out several sources of bias.

So I would say the jury is out on CRP.  I really don’t find it helpful in the high or low risk Framingham patient. It might be useful in the intermediate (10-20%) Framingham risk category, if they already have goal lipids.  If you found a CRP over 3, it might be motivating to encourage lifestyle modifications (perhaps Mediterranean diet?) to lower it.  I’m not convinced that we need to medicate all of these people with anything, although I’m sure I could find someone to disagree with that.

This is real.  Look.