Articles related to GUIDELINES/RECOMMENDATIONS

Delve into the changes in the updated Beers criteria and their implications for medication use in older patients. The American Geriatrics Society (AGS) has recently revised the Beers criteria. Significantly, these guidelines advise physicians to be cautious when prescribing medications like warfarin and sodium-glucose cotransporter-2 (SGLT2) inhibitors for patients over 65. Importantly, warfarin is now a drug to avoid in initial therapy for venous thromboembolism or nonvalvular atrial fibrillation unless alternatives are contraindicated or face significant usage barriers. The Beers criteria are organized into five distinct categories. These include potentially inappropriate medications, ones that might be inappropriate for patients with certain conditions, medications requiring careful usage, potential drug-drug interactions, and medications needing renal function-based dosage adjustments. An expert panel sifted through evidence from June 1, 2017, to May 31, 2022, to create these updates. These guidelines apply to patients aged 65 years and older in most care settings in the US, excluding hospice and end-of-life care situations. Among the notable changes since 2019 is the inclusion of warfarin. For older patients using warfarin long-term, continuation might be reasonable if they show well-controlled international normalized ratios and no adverse effects. Additional drugs introduced since 2019 include ticagrelor and SGLT2 inhibitors (use […]

This case study applies the newly revised CDC Clinical Practice Guideline for Prescribing Opioids for Pain to a patient with chronic neck pain. The patient, Joanna, is a 78-year-old woman who has undergone two neck surgeries and experiences worsening pain. Her pain ranges from 6 to 7 on average and can increase up to 8. She has tried various non-pharmacologic modalities, such as heat, ice, TENS, physical therapy, and massage therapy, but insurance limitations and cost have hindered her access to these treatments. Considering Joanna’s medical history, physical therapy and topical analgesics are identified as potential options. However, due to limitations and contraindications with other medications, the only feasible options for her are low-dose acetaminophen and topical analgesics. As a result, initiating a low-dose opioid therapy is considered appropriate, in addition to low-dose acetaminophen, OTC menthol and methyl salicylate cream, and a referral to physical medicine and rehabilitation. Before initiating opioids, the patient’s risk of side effects, including overdose, addiction, constipation, and hypogonadal axis suppression, should be discussed. Joanna’s Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD) score indicates a risk class of 4 out of 7, with a 15% estimated probability of an opioid-induced respiratory depression event […]

A 29-member specialist interest group (SIG) was formed, comprising representation from neurology, neuroradiology, anesthesia, neurosurgery, and patient advocacy. The SIG unanimously agreed on the scope and purpose of the guideline. Using a modified Delphi method, the SIG then created guideline statements for a number of question themes. A rigorous literature study, surveys of patients and healthcare professionals, and a review by numerous international experts on SIH all contributed to this process. Any patient presenting with orthostatic headache should be evaluated for spontaneous intracranial hypotension (SIH) and its possible diagnosis. MRI of the brain with contrast and the whole spine should be used as first-line imaging. The non-targeted epidural blood patch (EBP) is the first-line treatment and should be performed as soon as possible. The authors discuss treatment ideas and present criteria for doing myelography based on the spine MRI result and response to EBP. There are also recommendations for conservative care, symptomatic headache treatment, and management of SIH consequences.

Recent draft guidelines from the United States Preventive Services Task Force (USPSTF) propose a change in routine screening mammography recommendations. The new guidelines suggest that women should begin undergoing regular mammograms 10 years earlier than previously advised, starting at the age of 40. This recommendation applies to all individuals assigned female at birth. Simultaneously, FDA has made updates to federal mammography regulations, with a particular focus on reporting requirements related to breast density. These regulatory changes are motivated by studies indicating that approximately half of women over the age of 40 have dense breast tissue in concordance with the high prevalence of breast cancer in the population.

Clinicians are directed to the American College of Cardiology/American Heart Association pooled cohort equation, which takes into account age, gender, blood pressure, lipids, diabetes mellitus, and tobacco use but not family history. The USPSTF now advises against starting aspirin therapy in individuals 60 and older since there is no net benefit and the risk of damage may outweigh the benefit. The USPSTF guidelines are based on evidence from 13 trials, which show that aspirin has a slight advantage for select adults aged 40 to 59, but no net benefit (with the potential for harm) for patients aged 60 and older.

Internal medicine physicians play a crucial role in addressing osteoporosis challenges. Many at-risk patients are not screened or educated about fracture prevention, and a significant number of individuals with high fracture risk remain undiagnosed and untreated. Efforts should focus on recognizing fractures as diagnostic indicators, expanding screening, and implementing effective treatments. The recent clinical guideline emphasizes bisphosphonates as first-line therapy, denosumab as second-line, and injectable medications for high-risk cases. Primary care physicians should take an active role in screening, diagnosing, and treating osteoporosis to prevent future fractures, even without immediate subspecialist care. Risk assessment tools, healthy lifestyles, and consideration of benefits, harms, patient values, and costs in medication selection are important. Empowering primary care doctors is vital in bridging the treatment gap and preventing fractures.