Guidelines & Reports
Consensus Guideline: Low-Dose Oral Minoxidil for Hair Loss Management
24 Nov, 2024 | 20:27h | UTCIntroduction: Hair loss significantly affects patients’ quality of life, encompassing conditions like androgenetic alopecia, alopecia areata, and telogen effluvium. While topical minoxidil is FDA-approved for certain hair loss types, limitations have led to increased off-label use of low-dose oral minoxidil (LDOM). Recognizing the need for standardized guidance, an international panel of 43 dermatologists from 12 countries developed a consensus statement using a modified Delphi process to inform best practices for prescribing LDOM until more robust evidence emerges.
Key Recommendations:
- Patient Selection:
- Indications: LDOM may benefit adults and adolescents with androgenetic alopecia, age-related thinning, alopecia areata, telogen effluvium, traction alopecia, persistent chemotherapy-induced alopecia, and endocrine therapy–induced alopecia.
- Contraindications: LDOM is contraindicated in patients with hypersensitivity to minoxidil, significant drug interactions, history of pericardial effusion or tamponade, pericarditis, congestive heart failure, pulmonary hypertension with mitral stenosis, pheochromocytoma, and during pregnancy or breastfeeding.
- Precautions: Use cautiously in patients with tachycardia, arrhythmias, hypotension (blood pressure <90/60 mm Hg), impaired kidney function, or those undergoing dialysis.
- Dosing Guidelines:
- Adults:
- Females: Starting dose of 1.25 mg daily; dosing range 0.625 mg to 5 mg daily.
- Males: Starting dose of 2.5 mg daily; dosing range 1.25 mg to 5 mg daily.
- Adolescents (12–17 years):
- Females: Starting dose of 0.625 mg daily; dosing range 0.625 mg to 2.5 mg daily.
- Males: Starting dose of 1.25 mg daily; dosing range 1.25 mg to 5 mg daily.
- Considerations: Dosing influenced by sex, age, risk of systemic adverse effects, and desire to minimize hypertrichosis.
- Adults:
- Monitoring and Evaluation:
- Baseline Assessments: Routine labs and ECGs are not required unless precautions are present; consult specialists if needed.
- Adverse Effects Monitoring: Counsel patients on potential side effects like hypertrichosis, dizziness, tachycardia, and fluid retention; monitor for signs such as swelling or weight gain.
- Efficacy Expectations: Initial effects may be observed at three months; efficacy may take up to six months if transient shedding occurs.
- Adjunctive Therapies:
- Spironolactone: May be co-administered in female patients with hirsutism, acne, or polycystic ovary syndrome to enhance treatment efficacy and manage fluid retention.
- Beta-Blockers: Consider in consultation with specialists, especially for managing tachycardia.
- Preference Over Topical Minoxidil:
- LDOM may be preferred when topical minoxidil causes scalp irritation, is cosmetically unacceptable, ineffective, or when enhanced hypertrichosis is desired.
Conclusion: This consensus provides a structured approach for clinicians considering LDOM as an off-label treatment for hair loss. By outlining patient selection, dosing, monitoring, and when to seek specialist input, these recommendations aim to optimize patient outcomes and safety.
Review: Comparative Analysis of ESC and ESH Hypertension Guidelines
20 Nov, 2024 | 15:03h | UTCIntroduction: Hypertension remains a significant global health challenge with increasing prevalence and substantial morbidity and mortality rates. To address this, the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) have independently published updated guidelines on hypertension management. This review provides a pragmatic comparison of these guidelines, highlighting their major similarities and differences to assist clinicians in optimizing patient care.
Key Recommendations:
Shared Recommendations:
- Diagnosis Criteria: Both guidelines recommend diagnosing hypertension based on office systolic and diastolic blood pressures of ≥140/90 mmHg.
- Blood Pressure Targets: Both advocate aiming for an optimal blood pressure of <130/80 mmHg. The ESH emphasizes personalized targets for specific populations like the elderly, while the ESC adopts the ALARA (as low as reasonably achievable) principle.
- Out-of-Office Measurements: Emphasis is placed on home blood pressure monitoring and ambulatory measurements to confirm diagnoses and tailor treatments.
- Comprehensive Assessment: Both recommend thorough initial evaluations, including screening for orthostatic hypotension, comorbidities, and hypertension-mediated organ damage (HMOD).
- Early Treatment Initiation: Both suggest starting antihypertensive therapy promptly, preferably using a single-pill combination of two agents after lifestyle interventions.
- Treatment Goals and Follow-Up: Both aim for patients to reach blood pressure targets within three months, underscoring the importance of close monitoring.
- Adjunctive Therapies: The use of SGLT-2 inhibitors is recommended for patients with chronic kidney disease and/or heart failure. Renal denervation is considered for true resistant hypertension.
Differences:
- Blood Pressure Classification: The ESC introduces a new category of “elevated blood pressure,” altering patient classification but with minimal impact on practical management.
- Screening for Secondary Hypertension: The ESC strongly encourages screening for secondary hypertension, particularly primary aldosteronism; the ESH does not emphasize this as strongly.
- Age Stratification: Different age thresholds for the very elderly are used (ESH: ≥80 years; ESC: ≥85 years), with the ESH providing more detailed treatment personalization for this group.
- Treatment Targets Philosophy: The ESC supports the ALARA principle for blood pressure targets, aiming for the lowest achievable levels without adverse effects, while the ESH provides specific target ranges.
- Beta-Blocker Use: The ESH includes beta-blockers as first-line therapy options, whereas the ESC positions them as third-line agents.
Conclusion: Despite minor discrepancies, the ESC and ESH hypertension guidelines are largely concordant and based on the same evidence base. Both sets provide clear, pragmatic recommendations emphasizing early diagnosis, personalized treatment, and close follow-up. Clinicians can confidently use either guideline to inform practice, as both aim to improve patient outcomes by effectively managing hypertension in the primary care setting.
Guideline: Management of Urinary Tract Infections in Pediatrics and Adults
5 Nov, 2024 | 18:59h | UTCIntroduction: Urinary tract infections (UTIs) are among the most common infections worldwide, significantly impacting patient quality of life and imposing substantial clinical and economic burdens. Despite advancements in diagnosis and treatment, UTIs continue to cause high morbidity and mortality, ranging from simple cystitis to life-threatening sepsis. Addressing the discrepancy between evidence quality and recommendation strength in existing guidelines, the WikiGuidelines Group has developed a consensus statement. This guideline aims to provide evidence-based recommendations for the prevention, diagnosis, and management of UTIs across diverse clinical settings.
Key Recommendations:
- Cranberry Products:
- Recommendation: Cranberry juice or supplements are recommended for preventing symptomatic, culture-verified UTIs in women with recurrent UTIs, children, and individuals susceptible after interventions.
- Quality of Evidence: Moderate
- Recommendation Strength: Strong
- Methenamine Hippurate:
- Recommendation: Methenamine hippurate is recommended as an alternative to prophylactic antibiotics for preventing recurrent UTIs in patients with intact bladder anatomy.
- Quality of Evidence: Moderate
- Recommendation Strength: Strong
- Topical Estrogen:
- Recommendation: Vaginal estrogen therapy is recommended for postmenopausal women to reduce recurrent UTIs by restoring the vaginal microbiome.
- Quality of Evidence: High
- Recommendation Strength: Strong
- Empirical Treatment Regimens:
- Recommendation: For uncomplicated cystitis, nitrofurantoin is recommended as a first-line agent. For pyelonephritis, trimethoprim/sulfamethoxazole or a first-generation cephalosporin are reasonable first-line agents, depending on local resistance rates.
- Quality of Evidence: Moderate
- Recommendation Strength: Strong
- Treatment Duration for Acute Cystitis in Adults:
- Recommendation:
- Nitrofurantoin: 5 days
- Trimethoprim/sulfamethoxazole: 3 days
- Oral fosfomycin: Single dose
- Quality of Evidence: High
- Recommendation Strength: Strong
- Recommendation:
- Treatment Duration for Acute Pyelonephritis in Adults:
- Recommendation:
- Fluoroquinolones: 5–7 days
- Dose-optimized β-lactams: 7 days
- Quality of Evidence: High
- Recommendation Strength: Strong
- Recommendation:
- Antimicrobial Stewardship:
- Recommendation: De-escalation of antibiotics and the use of mostly or all oral treatment regimens are recommended to optimize antimicrobial use and reduce adverse effects.
- Quality of Evidence: High
- Recommendation Strength: Strong
Conclusion: The consensus highlights a significant lack of high-quality prospective data in many areas related to UTIs, limiting the ability to provide clear recommendations. Implementing these evidence-based guidelines can enhance patient care by promoting effective prevention strategies, accurate diagnosis based on clinical symptoms, appropriate treatment durations, and robust antimicrobial stewardship. This approach is expected to improve clinical outcomes, reduce antimicrobial resistance, and preserve the effectiveness of current treatments.
2023 VA/DoD Clinical Practice Guidelines for the Management of Headache
3 Nov, 2024 | 18:45h | UTCIntroduction: Headache disorders, notably migraine and tension-type headache (TTH), are among the most prevalent and disabling neurological conditions globally, significantly impacting individuals’ quality of life and imposing substantial societal costs. This 2023 guideline provides primary care clinicians with evidence-based recommendations for the evaluation, treatment, and prevention of migraine and TTH, aiming to enhance patient care and outcomes.
Key Recommendations:
- Acute Migraine Treatment:
- Triptans (eletriptan, frovatriptan, rizatriptan, sumatriptan, zolmitriptan) are strongly recommended for short-term migraine relief. (Strength: Strong for)
- Aspirin–Acetaminophen–Caffeine combination is strongly recommended for acute migraine treatment. (Strength: Strong for)
- Gepants (ubrogepant, rimegepant) are suggested as options for acute migraine management. (Strength: Weak for)
- NSAIDs (aspirin, ibuprofen, naproxen) and acetaminophen are suggested for acute migraine relief. (Strength: Weak for)
- Preventive Migraine Therapy:
- CGRP Monoclonal Antibodies (erenumab, fremanezumab, galcanezumab) are strongly recommended for preventing episodic or chronic migraine. (Strength: Strong for)
- Angiotensin Receptor Blockers (candesartan, telmisartan) are recommended for episodic migraine prevention. (Strength: Strong for)
- Topiramate and valproate are suggested for migraine prevention. (Strength: Weak for)
- Lisinopril, magnesium, memantine, and atogepant are suggested for preventing episodic migraine. (Strength: Weak for)
- OnabotulinumtoxinA injections are suggested for preventing chronic migraine but not episodic migraine. (Strength: Weak for chronic migraine; Weak against for episodic migraine)
- Gabapentin is not recommended for preventing episodic migraine. (Strength: Weak against)
- Tension-Type Headache Management:
- For acute TTH, ibuprofen (400 mg) or acetaminophen (1000 mg) are suggested. (Strength: Weak for)
- Amitriptyline is suggested for preventing chronic TTH. (Strength: Weak for)
- Nonpharmacologic Interventions:
- Physical Therapy is suggested for managing TTH and migraine. (Strength: Weak for)
- Aerobic Exercise or progressive strength training is suggested for preventing TTH and migraine. (Strength: Weak for)
- Injections and Procedures:
- Greater Occipital Nerve Block is suggested for short-term migraine treatment. (Strength: Weak for)
Conclusion: The 2023 VA/DoD Clinical Practice Guideline provides updated, evidence-based recommendations for managing migraine and TTH, incorporating new pharmacologic agents and nonpharmacologic interventions. The inclusion of newer medications, such as CGRP inhibitors, offers additional options for patients who may not respond to traditional therapies.
Multisociety Guidelines for Perioperative Management of GLP-1 Receptor Agonists
3 Nov, 2024 | 14:27h | UTCIntroduction: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have transformed the management of metabolic diseases such as type 2 diabetes, obesity, and heart failure by enhancing glycemic control and promoting satiety. However, their effect of delaying gastric emptying has raised perioperative safety concerns due to the risk of residual gastric contents leading to pulmonary aspiration during anesthesia. Reports of aspiration incidents and gastrointestinal side effects like nausea and vomiting have prompted the need for unified clinical guidance. This multisociety clinical practice guideline aims to provide recommendations for safely managing patients on GLP-1RAs during the perioperative period, balancing metabolic benefits with procedural risks.
Key Recommendations:
- Shared Decision-Making:
- Collaborative Approach: The continuation or discontinuation of GLP-1RAs should involve shared decision-making among the patient, surgical team, anesthesia providers, and prescribing clinicians.
- Risk Assessment: Evaluate factors that elevate the risk of delayed gastric emptying and aspiration, including:
- Dose Escalation Phase: Higher risk during dose escalation compared to maintenance.
- Higher Dosage: Increased gastrointestinal side effects with higher doses.
- Weekly Formulations: Greater side effects with weekly dosing compared to daily formulations.
- Gastrointestinal Symptoms: Presence of nausea, vomiting, abdominal pain, dyspepsia, or constipation.
- Comorbid Conditions: Conditions like gastroparesis, bowel dysmotility, or neurological disorders affecting gastric motility.
- Timing: Conduct risk assessments well in advance of surgery to allow for appropriate preoperative planning.
- Management of GLP-1RA Therapy:
- Continuation in Low-Risk Patients: GLP-1RAs may be continued preoperatively in patients without elevated risk factors.
- Balancing Risks in High-Risk Patients:
- Metabolic vs. Procedural Risks: Weigh the risks of aspiration against potential metabolic complications like hyperglycemia if GLP-1RAs are withheld.
- Avoiding Bias: Decisions should not be based solely on obesity status to prevent bias.
- Discontinuation Guidelines:
- Daily Formulations: Hold on the day of surgery.
- Weekly Formulations: Discontinue one week prior to surgery.
- Day-of-Surgery Assessment: All patients should be evaluated for symptoms of delayed gastric emptying on the day of the procedure, regardless of GLP-1RA usage.
- Minimizing Aspiration Risk:
- Preoperative Dietary Modifications:
- Liquid Diet: Implement a liquid diet for at least 24 hours before surgery, similar to protocols for colonoscopy and bariatric procedures.
- Gastric Content Assessment:
- Point-of-Care Ultrasound: Use gastric ultrasound to assess residual gastric contents when there is concern for delayed emptying, acknowledging potential limitations in resources and expertise.
- Anesthesia Plan Adjustments:
- Rapid Sequence Induction: Consider rapid sequence induction with tracheal intubation to minimize aspiration risk in patients with confirmed or suspected delayed gastric emptying.
- Procedure Continuation vs. Cancellation: Engage in shared decision-making to weigh the benefits of proceeding with the procedure against the risks, aiming to avoid unnecessary cancellations.
- Preoperative Dietary Modifications:
Conclusion: By adopting these recommendations, healthcare providers can enhance patient safety during the perioperative period for those receiving GLP-1RA therapy. The guidelines emphasize individualized care through shared decision-making, considering both metabolic benefits and procedural risks. Implementing these practices is expected to reduce aspiration incidents, optimize surgical outcomes, and ensure equitable care without bias against patients with obesity or metabolic disorders. As new evidence and medications emerge, these guidelines may be updated to reflect best practices.
Reference: Kindel TL, Wang AY, Wadhwa A, et al. Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Surgery for Obesity and Related Diseases. 2024; In Press. https://doi.org/10.1016/j.soard.2024.08.033
EULAR/PReS Guidelines for the Diagnosis and Management of Still’s Disease
20 Oct, 2024 | 17:41h | UTCIntroduction:
Still’s disease, encompassing systemic juvenile idiopathic arthritis (sJIA) and adult-onset Still’s disease (AOSD), is a systemic inflammatory disorder characterized by spiking fevers, rash, arthralgia or arthritis, and elevated inflammatory markers. Historically treated as separate entities, sJIA and AOSD are now recognized as the same disease continuum. To unify and optimize diagnosis and management across all ages, the European Alliance of Associations for Rheumatology (EULAR) and the Paediatric Rheumatology European Society (PReS) have developed comprehensive, evidence-based recommendations.
Key Recommendations:
- Unified Terminology: sJIA and AOSD are the same disease and should be collectively termed “Still’s disease” to standardize diagnosis and treatment. (Recommendation: strong)
- Rapid Diagnosis Using Operational Definitions: Key clinical features include spiking fever ≥39°C lasting ≥7 days, transient rash coinciding with fever spikes, arthralgia or arthritis, and elevated inflammatory markers (CRP, ESR, neutrophils, ferritin). Arthritis is supportive but not essential for diagnosis. (Strong)
- Diagnostic Biomarkers: Elevated serum interleukin-18 (IL-18) and S100 proteins strongly support the diagnosis and should be measured when available. (Moderate)
- Exclude Alternative Diagnoses: Carefully consider infections, malignancies, other immune-mediated inflammatory diseases, and monogenic autoinflammatory disorders to avoid misdiagnosis. (Strong)
- Treatment Goals: The ultimate goal is drug-free remission, defined as clinically inactive disease (CID) maintained for at least 6 months. CID entails absence of disease-related symptoms and normalization of ESR and CRP. Intermediate targets at specific time points guide treatment adjustments. (Strong)
- Early Use of IL-1 and IL-6 Inhibitors: To avoid prolonged glucocorticoid use, prioritize early initiation of interleukin-1 (IL-1) or interleukin-6 (IL-6) inhibitors upon diagnosis. (Strong)
- Glucocorticoid Tapering: Aim to achieve CID without glucocorticoids within 6 months. Maintain CID for 3–6 months before initiating tapering of biologic DMARDs. (Strong)
- Monitor for Complications: Be vigilant for life-threatening complications, including macrophage activation syndrome (MAS) and lung disease (LD), which require prompt recognition and management. (Strong)
- MAS Management: Consider MAS in patients with persistent fever, splenomegaly, elevated ferritin, cytopenias, abnormal liver function tests, coagulopathy, and hypertriglyceridemia. High-dose glucocorticoids are essential; anakinra, ciclosporin, and interferon-γ inhibitors may be added. (Strong)
- LD Screening and Management: Screen patients for LD via clinical assessment and pulmonary function tests; high-resolution CT scans are indicated for symptomatic patients. The presence of LD is not a contraindication for IL-1 or IL-6 inhibitors. (Strong)
Conclusion: Implementing these unified, evidence-based recommendations is expected to improve the diagnosis and management of Still’s disease across all ages, leading to earlier intervention, optimized treatment strategies, reduced complications, and enhanced patient outcomes, including achieving drug-free remission.
Systematic Review: Anifrolumab and Belimumab Improve Disease Control in Systemic Lupus Erythematosus; Voclosporin and Belimumab Effective in Lupus Nephritis
20 Oct, 2024 | 14:26h | UTCBackground: Systemic lupus erythematosus (SLE) management remains challenging due to disease heterogeneity and varying severity. New studies since the 2019 EULAR recommendations necessitate an update to inform clinical practice.
Objective: To analyze new evidence (2018–2022) for SLE management to inform the 2023 update of the European League Against Rheumatism (EULAR) recommendations.
Methods: Systematic literature reviews (SLRs) were conducted in Medline and Cochrane Library databases, covering publications from January 2018 to December 2022. Research focused on five domains: (1) efficacy and safety of SLE treatments, (2) benefits of remission/low disease activity, (3) risks of treatment tapering/withdrawal, (4) management of SLE with antiphospholipid syndrome, and (5) safety of varicella zoster virus (VZV) and SARS-CoV2 immunizations.
Results: A total of 439 relevant articles were identified, predominantly observational studies of low or moderate quality. High-quality randomized controlled trials (RCTs) documented the efficacy of anifrolumab, a type 1 interferon receptor inhibitor, in non-renal SLE, and belimumab and voclosporin, a novel calcineurin inhibitor, in lupus nephritis (LN) when compared with standard care. For specific organ manifestations outside LN, high-quality data were lacking. Multiple observational studies confirmed the benefits of attaining clinical remission or low disease activity, reducing the risk of adverse outcomes. Two RCTs with some concerns found higher relapse rates in patients who discontinued glucocorticoids or immunosuppressants in SLE and LN, respectively; however, observational studies suggest that treatment withdrawal may be feasible in a subset of patients.
Conclusions: Anifrolumab and belimumab achieve better disease control than standard care in extrarenal SLE, while combination therapies with belimumab and voclosporin showed higher response rates in high-quality RCTs in LN. Remission and low disease activity are associated with favorable long-term outcomes. In patients achieving these targets, glucocorticoids and immunosuppressive therapy may be gradually tapered.
Implications for Practice: Clinicians should consider anifrolumab and belimumab for extrarenal SLE, and belimumab and voclosporin for LN. Monitoring and aiming for remission or low disease activity can reduce adverse outcomes. Gradual tapering of glucocorticoids and immunosuppressants may be considered in patients achieving these targets, with careful monitoring for relapse.
Study Strengths and Limitations: Strengths include comprehensive SLRs and inclusion of recent high-quality RCTs. Limitations involve the predominance of low-quality observational studies, lack of high-quality data for specific organ manifestations, and potential bias in treatment withdrawal studies.
Future Research: Further high-quality RCTs are needed to assess treatments for specific organ manifestations outside LN. Long-term studies on tapering and withdrawal strategies of immunosuppressive therapies are necessary to guide safe practice.
Guideline: SCAI Expert Consensus on Management of STEMI Patients Undergoing Primary PCI
13 Oct, 2024 | 12:44h | UTCIntroduction: ST-elevation myocardial infarction (STEMI) is a leading cause of morbidity and mortality, requiring rapid diagnosis and timely reperfusion. While primary percutaneous coronary intervention (PCI) is the preferred reperfusion method, existing guidelines lack detailed procedural and technical recommendations for the cardiac catheterization laboratory (CCL). The Society for Cardiovascular Angiography & Interventions (SCAI) presents this expert consensus statement to provide best practices for CCL team readiness, optimal angiography and intervention techniques, management of special circumstances and anatomical subsets, and strategies to improve quality of care in STEMI patients undergoing primary PCI.
Key Recommendations:
- CCL Team Readiness:
- Prehospital notification and ECG transmission expedite care.
- Implement emergency department (ED) bypass when feasible.
- Perform a focused cardiovascular assessment prior to PCI.
- Arterial Access:
- Prefer transradial access over femoral to reduce complications.
- Use ultrasound guidance and contemporary techniques for femoral access when necessary.
- Diagnostic Assessment:
- Conduct complete coronary angiography during the index procedure.
- Measure left ventricular end-diastolic pressure (LVEDP) to guide management.
- Managing Thrombus:
- Assess thrombus burden after wire crossing.
- Use bail-out aspiration thrombectomy selectively for large thrombus burden.
- Consider parenteral or intracoronary antiplatelet agents for refractory thrombus.
- Managing No-Reflow:
- Administer intracoronary vasodilators to the distal bed.
- Enhance coronary perfusion pressure by augmenting mean arterial pressure and reducing LVEDP.
- Intracoronary Imaging:
- Encourage routine use of IVUS or OCT to guide PCI.
- Employ intracoronary imaging to investigate stent thrombosis or suspected nonatherosclerotic causes.
- Special Circumstances:
- In cardiogenic shock, perform right heart catheterization and consider mechanical circulatory support.
- After failed fibrinolysis, proceed with immediate catheterization and rescue PCI.
- In multivessel disease, complete revascularization is recommended.
- Anatomical Subsets:
- Use plaque modification techniques for calcified lesions.
- Prefer a provisional one-stent strategy in bifurcation lesions.
- Focus on restoring flow in coronary aneurysms.
- Nonatherosclerotic STEMI Causes:
- Administer intracoronary nitroglycerin to identify epicardial vasospasm.
- Manage spontaneous coronary artery dissection conservatively if flow is preserved.
- Use thrombectomy for coronary embolism.
- Investigate MINOCA with additional imaging and testing.
- Quality Improvement:
- Track all STEMI cases to assess treatment times and outcomes for continuous improvement.
Conclusion: Adherence to these recommendations is expected to enhance patient outcomes by optimizing procedural strategies, reducing complications, and improving survival in STEMI patients undergoing primary PCI.
ATS Guideline: Evaluation and Management of Obesity Hypoventilation Syndrome
12 Oct, 2024 | 23:04h | UTCIntroduction: Obesity Hypoventilation Syndrome (OHS) is a serious condition characterized by obesity (BMI ≥30 kg/m²), sleep-disordered breathing, and daytime hypercapnia (PaCO₂ ≥45 mm Hg), after excluding other causes of hypoventilation. Recognizing the need for standardized evaluation and management, the American Thoracic Society (ATS) has developed comprehensive guidelines. These aim to improve early recognition, optimize treatment strategies, and reduce variability in clinical practice to enhance patient outcomes.
Key Recommendations:
- Screening for OHS:
- Serum Bicarbonate Measurement: For patients with low to moderate probability of OHS (<20%), a serum bicarbonate level can guide the need for arterial blood gas (ABG) analysis. A bicarbonate level <27 mmol/L suggests that measuring PaCO₂ may be unnecessary, while levels ≥27 mmol/L indicate that ABG measurement is warranted. (Quality of evidence: very low; Recommendation: conditional)
- PaCO₂ Measurement: In patients with a high pretest probability of OHS, direct measurement of PaCO₂ is recommended over relying on serum bicarbonate or oxygen saturation levels. (Quality of evidence: very low; Recommendation: conditional)
- Positive Airway Pressure (PAP) Therapy:
- Use of PAP: Stable ambulatory patients diagnosed with OHS should be treated with PAP during sleep to improve gas exchange and alleviate symptoms. (Quality of evidence: very low; Recommendation: conditional)
- Choice of Modality: For patients with OHS and coexisting severe obstructive sleep apnea (OSA) (apnea–hypopnea index ≥30 events/hour), continuous positive airway pressure (CPAP) is suggested as the first-line treatment over noninvasive ventilation (NIV). (Quality of evidence: very low; Recommendation: conditional)
- Hospitalized Patients:
- Discharge Planning: Patients hospitalized with respiratory failure suspected of having OHS should be discharged with NIV therapy until outpatient diagnostic evaluations and PAP titration can be completed, ideally within 2–3 months. (Quality of evidence: very low; Recommendation: conditional)
- Weight Loss Interventions:
- Significant Weight Reduction: Patients with OHS are advised to engage in weight-loss interventions aiming for a sustained loss of 25–30% of actual body weight to resolve hypoventilation. Bariatric surgery may be considered to achieve this goal when appropriate. (Quality of evidence: very low; Recommendation: conditional)
Conclusion: Implementing these guidelines is expected to enhance the early detection and standardized management of OHS. By following these recommendations, healthcare providers can improve patient care, reduce morbidity and mortality associated with OHS, and promote better clinical outcomes.
Review: Management of Atrial Fibrillation in Older Adults
12 Oct, 2024 | 19:52h | UTCIntroduction: Atrial fibrillation (AF) predominantly affects adults over 65 years old and often coexists with multiple chronic conditions, polypharmacy, and geriatric syndromes such as frailty. Despite this, most randomized controlled trials and guidelines do not tailor recommendations specifically for older adults with these complexities. This review addresses the gap by synthesizing evidence and applying aging science principles to AF management, aiming to provide a framework that prioritizes patients’ goals across the spectrum of older adults—from fit individuals to those who are frail or at the end of life.
Key Recommendations:
- Individualized Care Approach: Clinicians should tailor AF management by considering patients’ comorbidities, frailty, and personal health goals. Tools like the Clinical Frailty Scale and comprehensive geriatric assessment can aid in assessing fitness and frailty.
- Screening for AF: Systematic population-level screening for AF in older adults has not conclusively shown a reduction in stroke incidence. Decisions regarding screening should be individualized, weighing the potential benefits and burdens.
- Lifestyle Interventions: For functional older adults, lifestyle modifications such as weight loss, moderate physical activity, blood pressure control, and alcohol avoidance are recommended to prevent and manage AF.
- Symptom Management: Use validated patient-reported outcome measures to assess and manage AF symptoms effectively, aligning treatment with patients’ experiences and quality of life goals.
- Rate and Rhythm Control:
- Fit Older Adults: Early rhythm control is preferred, with catheter ablation showing superiority over anti-arrhythmic drugs in maintaining sinus rhythm and improving quality of life.
- Multimorbid/Frail Older Adults: Treatment should be individualized, balancing the risks and benefits of anti-arrhythmic drugs versus catheter ablation.
- Heart Failure Coexistence: Catheter ablation is recommended over medical therapy for patients with AF and heart failure with reduced ejection fraction.
- Anticoagulation Therapy:
- General Recommendation: Direct oral anticoagulants (DOACs) are preferred over warfarin due to similar efficacy and lower bleeding risk.
- Multimorbid/Frail Older Adults: Apixaban is favored for its lower bleeding risk. Decisions should consider life expectancy and patient preferences.
- End-of-Life Care: De-escalation of anticoagulation may be appropriate when risks outweigh benefits or when it aligns with the patient’s comfort-focused goals.
- Left Atrial Appendage Closure (LAAC):
- Indications: LAAC is considered for patients with contraindications to long-term anticoagulation.
- Considerations: Procedural risks should be weighed against potential benefits, especially in frail older adults.
Conclusion: Implementing an individualized, goal-directed approach to AF management in older adults can enhance patient care by aligning treatments with patients’ health priorities and improving clinical outcomes. Recognizing the heterogeneity among older adults with AF, clinicians should adopt strategies that consider fitness, frailty, comorbidities, and patient preferences to optimize care across the aging spectrum.
Management of Ascites in Cirrhosis: Key Recommendations from the British Society of Gastroenterology Guidelines
12 Oct, 2024 | 18:23h | UTCIntroduction: Ascites, the pathological accumulation of fluid within the peritoneal cavity, is a common and serious complication of cirrhosis, indicating advanced liver disease and portending increased morbidity and mortality. Recognizing the need for updated clinical guidance, the British Society of Gastroenterology (BSG), in collaboration with the British Association for the Study of the Liver (BASL), has issued comprehensive guidelines. These aim to standardize the diagnosis and management of ascites in cirrhotic patients, incorporating recent advances to optimize patient outcomes.
Key Recommendations:
- Diagnostic Paracentesis: It is strongly recommended that all patients with new-onset ascites undergo diagnostic paracentesis to measure total protein concentration and calculate the serum-ascites albumin gradient (SAAG). (Quality of evidence: moderate; Recommendation: strong)
- Spontaneous Bacterial Peritonitis (SBP): Prompt diagnostic paracentesis should be performed in hospitalized patients with ascites, especially those with gastrointestinal bleeding or signs of infection, to rule out SBP. An ascitic neutrophil count >250/mm³ confirms SBP, necessitating immediate empirical antibiotic therapy tailored to local resistance patterns. (Quality of evidence: moderate; Recommendation: strong)
- Dietary Salt Restriction: Patients should restrict dietary sodium intake to no more than 5–6.5 grams per day (87–113 mmol), equivalent to a no-added-salt diet, to manage fluid accumulation effectively. (Quality of evidence: moderate; Recommendation: strong)
- Diuretic Therapy: For initial moderate ascites, spironolactone monotherapy is recommended. In cases of recurrent severe ascites, combination therapy with spironolactone and furosemide is advised. Regular monitoring for adverse events such as electrolyte imbalances and renal impairment is essential. (Quality of evidence: moderate; Recommendation: strong)
- Large Volume Paracentesis (LVP): LVP is a safe and effective treatment for refractory ascites. Informed consent is required, and routine coagulation studies or prophylactic blood product infusions before the procedure are not recommended. (Quality of evidence: moderate; Recommendation: strong)
- Use of Human Albumin Solution (HAS): After LVP exceeding 5 liters, infusion of HAS at 8 grams per liter of ascites removed is strongly recommended to prevent circulatory dysfunction. (Quality of evidence: high; Recommendation: strong)
- Transjugular Intrahepatic Portosystemic Shunt (TIPSS): TIPSS should be considered for patients with refractory ascites not responding to medical therapy, with caution exercised in patients over 70 years or those with significant comorbidities. (Quality of evidence: high; Recommendation: strong)
- Non-Selective Beta-Blockers (NSBBs): The presence of refractory ascites is not a contraindication for NSBB therapy. Patients should be closely monitored, and dose adjustments made in cases of hypotension or renal dysfunction. (Quality of evidence: moderate; Recommendation: strong)
- Palliative Care: Patients unsuitable for liver transplantation should be offered palliative care referral to focus on symptom management and quality of life improvement. Alternative interventions for refractory ascites may also be considered. (Quality of evidence: weak; Recommendation: strong)
Conclusion: Implementation of these evidence-based guidelines is expected to enhance patient care by promoting early diagnosis, preventing complications, and standardizing management strategies for ascites in cirrhosis. Adherence to these recommendations can improve clinical outcomes, reduce hospitalizations, and enhance the quality of life for affected patients.
Guideline Summary: Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitors for Adults with Chronic Kidney Disease
4 Oct, 2024 | 11:14h | UTCIntroduction
A recent clinical practice guideline published in The BMJ titled “Sodium-glucose cotransporter-2 (SGLT-2) inhibitors for adults with chronic kidney disease” provides evidence-based recommendations on the use of SGLT-2 inhibitors in adults with chronic kidney disease (CKD), regardless of diabetes status. The guideline aims to assist clinicians in making informed decisions to improve patient outcomes in CKD management.
Key Recommendations and Patient Care Implications
- Risk Stratification
- Assessment: Patients with CKD should be stratified based on their risk of disease progression and complications using estimated glomerular filtration rate (eGFR) and albuminuria levels, following the Kidney Disease Improving Global Outcomes (KDIGO) classification.
- Clinical Implication: Proper risk stratification guides the intensity of treatment and monitoring.
- Use of SGLT-2 Inhibitors
- Low to Moderate Risk Patients: For adults at low or moderate risk, the guideline suggests administering SGLT-2 inhibitors (weak recommendation in favor).
- Patient Care Impact: Clinicians should discuss potential benefits and risks with patients, considering individual preferences.
- High to Very High Risk Patients: For adults at high or very high risk, a strong recommendation is made to administer SGLT-2 inhibitors.
- Patient Care Impact: Clinicians should prioritize initiating SGLT-2 inhibitors in these patients to reduce risks of mortality and progression to kidney failure.
- Low to Moderate Risk Patients: For adults at low or moderate risk, the guideline suggests administering SGLT-2 inhibitors (weak recommendation in favor).
- Benefits of SGLT-2 Inhibitors
- Outcomes: Reduction in all-cause mortality, cardiovascular mortality, hospitalization for heart failure, kidney failure, non-fatal myocardial infarction, and non-fatal stroke.
- Clinical Implication: SGLT-2 inhibitors provide significant protective effects on cardiovascular and kidney health in CKD patients.
- Potential Harms and Monitoring
- Adverse Effects: Minimal increase in risks of acute kidney injury requiring dialysis, bone fractures, lower limb amputations, ketoacidosis, genital infections, or symptomatic hypovolemia.
- Patient Counseling: Patients should be informed about possible side effects and advised on when to seek medical attention.
- Monitoring: Routine laboratory monitoring is not generally necessary, except in high-risk individuals.
- Practical Considerations for Prescribing
- Initiation: Start SGLT-2 inhibitors in patients with eGFR ≥20 mL/min/1.73 m².
- Continuation: Medications can be continued even if eGFR falls below 20 mL/min/1.73 m² until dialysis is initiated.
- Dosage: Initiate at the highest possible dose without the need for titration.
- Drug Selection: Canagliflozin, dapagliflozin, and empagliflozin are suitable options.
- Concurrent Medications: Review and adjust diuretics to prevent volume depletion.
- Patient Education and Self-Management
- Sick Day Rules: Advise patients to temporarily discontinue SGLT-2 inhibitors during acute illnesses causing dehydration.
- Lifestyle Modifications: Encourage adherence to medication and healthy lifestyle changes to enhance treatment efficacy.
- Applicability and Exceptions
- Applicable Populations: Recommendations apply broadly to adults with CKD, with or without type 2 diabetes.
- Exceptions: Caution or alternative approaches may be necessary for patients:
- Receiving kidney replacement therapy.
- With kidney transplants, polycystic kidney disease, rare kidney diseases.
- With eGFR <20 mL/min/1.73 m² not on replacement therapy.
Conclusion
The guideline underscores the importance of incorporating SGLT-2 inhibitors into the management plan for adults with CKD to improve survival and reduce cardiovascular and kidney-related complications. Clinicians should evaluate each patient’s risk profile and engage in shared decision-making to optimize treatment outcomes.
2024 ESC Guidelines for the Management of Chronic Coronary Syndromes
1 Sep, 2024 | 18:49h | UTCIntroduction: The 2024 guidelines were developed by the European Society of Cardiology (ESC) with the endorsement of the European Association for Cardio-Thoracic Surgery (EACTS). These guidelines provide updated recommendations for the management of chronic coronary syndromes (CCS), focusing on the diagnosis, treatment, and long-term care of patients with stable coronary artery disease (CAD).
Key Points:
1 – History and Risk Assessment:
– Detailed assessment of cardiovascular risk factors, medical history, and symptom characteristics is essential in patients with suspected CCS.
– Symptoms like chest pain triggered by emotional stress, dyspnea on exertion, or fatigue should be considered potential angina equivalents.
2 – Diagnostic Testing:
– Coronary Computed Tomography Angiography (CCTA): Recommended as a first-line diagnostic tool for patients with low to moderate pre-test likelihood of obstructive CAD.
– Stress Imaging: Stress echocardiography, SPECT, PET, or cardiac MRI is recommended for those with moderate to high pre-test likelihood to diagnose myocardial ischemia and estimate the risk of major adverse cardiovascular events (MACE).
3 – Revascularization Indications:
– Symptom Relief: Revascularization is recommended for patients with obstructive CAD who have significant symptoms despite optimal medical therapy.
– Prognostic Benefit: Indicated in patients with left main coronary artery disease, severe three-vessel disease, or two-vessel disease including proximal left anterior descending artery stenosis, particularly if associated with reduced left ventricular function.
– High-Risk Anatomical Features: Revascularization is advised when significant stenosis is present in patients with high-risk anatomical features identified by imaging, especially if non-invasive testing shows a large area of ischemia.
4 – Lifestyle and Risk Management:
– A comprehensive approach to cardiovascular risk reduction, including lifestyle changes (e.g., smoking cessation, diet, and physical activity) and guideline-directed medical therapy, is strongly recommended.
– Home-based cardiac rehabilitation and digital health interventions are suggested to improve long-term adherence to healthy behaviors.
5 – Antianginal and Antithrombotic Therapy:
– Tailoring antianginal therapy based on individual patient characteristics, comorbidities, and local drug availability is recommended.
– Long-term antithrombotic therapy with aspirin or clopidogrel is recommended for patients with prior myocardial infarction or revascularization.
Conclusion: The 2024 ESC guidelines emphasize a patient-centered approach, integrating advanced diagnostic tools and personalized therapeutic strategies to optimize outcomes for patients with chronic coronary syndromes. The guidelines highlight the importance of detailed risk assessment, appropriate use of diagnostic imaging, clear criteria for revascularization, and a strong focus on lifestyle interventions alongside pharmacological management.
Updated ESC Hypertension Guidelines 2024: Intensified Blood Pressure Targets and New Categories – Eur Heart J
31 Aug, 2024 | 19:54h | UTCIntroduction:
The 2024 ESC Guidelines for managing elevated blood pressure (BP) and hypertension were developed by the European Society of Cardiology (ESC) and endorsed by the European Society of Endocrinology (ESE) and the European Stroke Organisation (ESO). These guidelines introduce significant updates to BP management, including more intensive treatment targets and the introduction of a new category for “Elevated BP.”
Key Points:
1 – New Intensive BP Target: For most patients receiving BP-lowering medication, the guidelines now recommend a systolic BP treatment target range of 120-129 mmHg. This marks a significant shift from previous guidelines, which suggested a less aggressive initial target.
2 – New ‘Elevated BP’ Category: The guidelines introduce a new category, “Elevated BP,” defined as a systolic BP of 120-139 mmHg and/or diastolic BP of 70-89 mmHg. This aims to identify more patients at risk of cardiovascular events, such as heart attacks and strokes, before they meet the traditional threshold for hypertension.
3 – Pragmatic BP Management: For patients who cannot tolerate the intensive BP target, the guidelines recommend aiming for a BP that is “as low as reasonably achievable” (ALARA), particularly in frail or older individuals.
4 – Lifestyle Modifications: The guidelines emphasize lifestyle interventions, including dietary changes like potassium supplementation and new exercise recommendations, as first-line strategies for managing BP.
5 – Renal Denervation: For the first time, the guidelines include recommendations on the use of renal denervation—a procedure for patients with resistant hypertension that has not responded to standard treatments. This is not recommended as a first-line treatment but may be considered in specific high-risk cases.
Conclusion:
These new guidelines represent a major update in the management of hypertension, particularly in promoting more aggressive BP targets to reduce cardiovascular risks. The inclusion of a new BP category and recommendations for renal denervation highlight the guidelines’ focus on early intervention and advanced treatment options.
2024 ESC Guidelines for the Management of Atrial Fibrillation – Eur Heart J
31 Aug, 2024 | 19:34h | UTCIntroduction: The 2024 guidelines for the management of atrial fibrillation (AF) were developed by the European Society of Cardiology (ESC) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) and other specialized associations. These guidelines aim to provide evidence-based recommendations for the diagnosis, treatment, and management of AF, with a focus on improving patient outcomes through a multidisciplinary approach.
Key Points:
1 – Patient-Centered Care and Education:
– Education directed at patients, caregivers, and healthcare professionals is essential for optimizing shared decision-making. This approach ensures that treatment options are discussed openly, considering both the benefits and risks.
2 – Comorbidity and Risk Factor Management:
– Diuretics are recommended for patients with AF, heart failure (HF), and congestion to alleviate symptoms and improve AF management.
– Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are recommended for patients with AF and HF, regardless of left ventricular ejection fraction (LVEF), to reduce the risk of hospitalization and cardiovascular death.
3 – Stroke Prevention and Anticoagulation:
– Oral anticoagulation is recommended for all patients with clinical AF and elevated thromboembolic risk, particularly those with a CHA2DS2-VA score of 2 or more.
– Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists (VKAs) in eligible patients undergoing cardioversion.
4 – Rate and Rhythm Control:
– Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs for heart rate control in patients with AF and LVEF >40%.
– Catheter ablation is recommended as a first-line treatment option in patients with paroxysmal AF to reduce symptoms and prevent AF progression.
Conclusion: The 2024 ESC guidelines emphasize a patient-centered, multidisciplinary approach to AF management, with a strong focus on the early identification and management of comorbidities and risk factors. The guidelines also advocate for the use of DOACs in stroke prevention and recommend specific strategies for rate and rhythm control to enhance patient outcomes.
Updated Guidelines for Potentially Inappropriate Medication Use in Older Adults (2023 AGS Beers Criteria®) – J Am Geriatr Soc
31 Aug, 2024 | 19:20h | UTCIntroduction:
The American Geriatrics Society (AGS) has released the 2023 update to the AGS Beers Criteria®, a critical tool for healthcare professionals aimed at improving the safety of medication prescribing in adults aged 65 and older. The guidelines identify potentially inappropriate medications (PIMs) that should generally be avoided in older adults due to the heightened risk of adverse effects.
Key Points:
1 – Anticholinergic Drugs: First-generation antihistamines (e.g., diphenhydramine) should be avoided due to their high anticholinergic activity, which can lead to confusion, dry mouth, constipation, and other serious side effects, including increased risk of falls and dementia.
2 – Nitrofurantoin: Should be avoided in individuals with a creatinine clearance less than 30 mL/min due to the risk of pulmonary toxicity, hepatotoxicity, and peripheral neuropathy.
3 – Cardiovascular Drugs: Aspirin for primary prevention of cardiovascular disease is not recommended in older adults due to the increased risk of bleeding and lack of clear benefit. Similarly, warfarin is discouraged as an initial treatment for nonvalvular atrial fibrillation or venous thromboembolism in favor of Direct Oral Anticoagulants (DOACs) unless DOACs are contraindicated.
4 – Central Nervous System (CNS) Medications: Benzodiazepines and non-benzodiazepine receptor agonist hypnotics (“Z-drugs”) are associated with increased risks of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults and should generally be avoided.
5 – Antipsychotics: Should be avoided for the treatment of behavioral problems in dementia or delirium due to the increased risk of stroke and greater rates of cognitive decline and mortality unless required for specific psychiatric conditions like schizophrenia or bipolar disorder.
Conclusion:
The 2023 AGS Beers Criteria® continues to serve as an essential guide for minimizing the risks associated with medication use in older adults. It emphasizes the need for individualized care and the importance of weighing the benefits and risks of medications, particularly in vulnerable populations.
Updated Guidelines on Perioperative Management of Anticoagulant and Antiplatelet Therapy for Interventional Techniques – Pain Physician
18 Aug, 2024 | 14:52h | UTCIntroduction: The American Society of Interventional Pain Physicians (ASIPP) has published updated guidelines for the perioperative management of patients undergoing interventional techniques while receiving antiplatelet and anticoagulant therapy. These guidelines are essential for clinicians to balance the risk of thromboembolism against the risk of bleeding during interventional procedures.
Key Points:
1 – Risk of Thromboembolic Events:
– Thromboembolic events have a higher risk of morbidity and mortality compared to the risk of epidural hematoma. Thus, interruption of antithrombotic therapy should be carefully considered.
2 – Risk Stratification of Procedures:
– Interventional techniques are classified into three categories based on risk: low, moderate, or high. For high-risk procedures, cessation of anticoagulant or antiplatelet therapy is recommended, whereas for low to moderate-risk procedures, therapy may continue under certain conditions.
3 – Management of Direct Oral Anticoagulants (DOACs):
– DOACs such as dabigatran, apixaban, rivaroxaban, and edoxaban should generally be discontinued for 2 days before high-risk procedures and one day for moderate-risk procedures. Adjustments are needed based on renal function, specially for dabigatran.
4 – Discontinuation of Aspirin:
– For high-risk interventional procedures, discontinuation of aspirin (81 or 325 mg) is recommended 6 days before the procedure. However, for low to moderate-risk procedures, aspirin therapy may be continued or stopped for 3 days depending on individual risk factors and clinical judgment.
5 – Discontinuation of Other Antiplatelet Agents:
– Clopidogrel (Plavix) and Prasugrel (Effient): These agents should be discontinued 6 days before high-risk procedures. For low-risk procedures, these medications can be continued.
– Ticagrelor (Brilinta): Discontinue for 5 days before high-risk procedures, with consideration of patient-specific risk factors.
6 – Timing for Restarting Therapy:
– Antithrombotic therapy should typically be resumed within 12-24 hours after low to moderate-risk procedures and within 24-48 hours after high-risk procedures, depending on bleeding risk and patient status.
7 – Shared Decision-Making:
– Decisions on whether to continue or discontinue antithrombotic therapy should involve shared decision-making between the patient, the interventional pain specialist, and other treating physicians, considering all associated risks.
Conclusion: These guidelines provide a comprehensive framework for managing the delicate balance between thromboembolic and bleeding risks in patients on anticoagulant or antiplatelet therapy undergoing interventional procedures. They emphasize the importance of personalized care and multidisciplinary collaboration.
CDC Updates Contraceptive Guidelines for 2024 – Centers for Disease Control and Prevention
18 Aug, 2024 | 13:51h | UTCIntroduction: The Centers for Disease Control and Prevention (CDC) has released updated recommendations in the “U.S. Selected Practice Recommendations for Contraceptive Use, 2024” and “U.S. Medical Eligibility Criteria for Contraceptive Use, 2024.” These guidelines provide healthcare providers with the latest evidence-based recommendations to support patient-centered contraceptive care, aiming to remove unnecessary barriers and ensure equitable access to contraception.
Key Points:
1 – Intrauterine Device (IUD) Placement:
– Routine use of misoprostol is not recommended for IUD placement, except in selected cases. Lidocaine (topical or paracervical block) is newly recommended to reduce patient pain during IUD placement.
2 – Bleeding Irregularities with Implants:
– Hormonal treatments and antifibrinolytic agents may improve bleeding irregularities associated with implant use, although bleeding often recurs after stopping treatment. NSAIDs and selective estrogen-receptor modulators may also be effective, with benefits persisting post-treatment.
3 – Testosterone Use and Pregnancy Risk:
– Testosterone therapy may not prevent pregnancy in transgender, gender-diverse, and nonbinary individuals with a uterus. Contraceptive counseling and services should be offered to those at risk of pregnancy who do not desire it.
4 – Self-Administration of Injectable Contraceptives:
– Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) should be available for self-administration, providing an additional option for those seeking injectable contraception.
5 – Updates in Medical Eligibility Criteria:
– The 2024 guidelines include revised recommendations for patients with chronic kidney disease, updates for those who are breastfeeding, postpartum, or post-abortion, and considerations for individuals with obesity, cardiovascular conditions, and other comorbidities.
6 – Patient-Centered Counseling:
– The guidelines emphasize the importance of providing contraceptive care in a noncoercive manner, supporting the individual’s values, goals, and reproductive autonomy. Healthcare providers are encouraged to recognize and address structural inequities and avoid discrimination in contraceptive counseling.
Conclusion: These updated guidelines from the CDC are designed to support healthcare providers in delivering equitable, patient-centered contraceptive care. By removing unnecessary barriers and providing clear guidance on managing complex contraceptive issues, the recommendations aim to improve access to contraception and support informed, autonomous decision-making among patients.
Guideline Reference: Curtis, K. M., Nguyen, A. T., Tepper, N. K., et al. (2024). U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recommendations and Reports, 73(3).
2024 ACC Expert Consensus Decision Pathway on Clinical Assessment, Management, and Trajectory of Patients Hospitalized With Heart Failure – J Am Coll Cardiol
14 Aug, 2024 | 12:47h | UTCIntroduction: The American College of Cardiology (ACC) has released a focused update on the 2019 Expert Consensus Decision Pathway (ECDP) for the management of patients hospitalized with heart failure (HF). This update reflects new evidence and aligns with the latest ACC/AHA/HFSA heart failure guidelines.
Key Points:
1 – SGLT Inhibitors in Hospitalization:
– The update emphasizes the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors during hospitalization for heart failure, regardless of left ventricular ejection fraction (LVEF). These medications should be initiated early, provided the patient is hemodynamically stable and there are no contraindications such as type 1 diabetes or severe kidney dysfunction.
2 – Triage and Admission Criteria:
– Patients with a new diagnosis of HF with rapidly progressing symptoms, severe congestion, or higher disease complexity should generally be admitted from the emergency department (ED). Some low-risk patients may be managed in an observation unit or via Hospital at Home (HaH) programs.
3 – Daily Trajectory Review:
– The clinical trajectory of hospitalized HF patients should be reviewed daily to monitor for effective decongestion and the need for initiation of guideline-directed neurohormonal therapies. Adjustments should be made based on patient response.
4 – Neurohormonal Therapy Optimization:
– Strategies for optimizing neurohormonal therapies, including beta-blockers, angiotensin receptor/neprilysin inhibitors (ARNIs)/angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), and mineralocorticoid antagonists (MRAs), are updated. Therapy should be personalized based on patient tolerance, hemodynamics, and kidney function.
5 – Decongestion Strategies:
– The update provides enhanced guidance on diuretic therapy, including the use of dual nephron blockade and carbonic anhydrase inhibitors like acetazolamide for patients not responding adequately to loop diuretics.
6 – Palliative Care Integration:
– The role of palliative care has been highlighted, particularly for patients with worsening HF or those not responding to standard treatments. Early referral to palliative care can improve advance directive completion rates and reduce readmissions.
7 – Discharge and Follow-Up:
– Detailed discharge planning is crucial, including providing patients and caregivers with comprehensive information on medications, follow-up appointments, and the importance of adhering to the prescribed regimen. Telehealth may be utilized for post-discharge follow-up.
Conclusion: This focused update to the ACC ECDP provides essential guidance for the clinical management of patients hospitalized with heart failure. It emphasizes the early initiation of SGLT inhibitors, careful daily trajectory reviews, optimization of neurohormonal therapies, and the integration of palliative care. These updates aim to improve patient outcomes by addressing both short-term and long-term management strategies.
2024 Update to the ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure – J Am Coll Cardiol
14 Aug, 2024 | 12:26h | UTCIntroduction:
The American Heart Association (AHA) and American College of Cardiology (ACC) have released the 2024 update to the 2020 clinical performance and quality measures for adults with heart failure. This update aligns with the latest 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure and introduces new performance and quality measures to improve patient care.
Key Points:
1 – Performance Measures (PM):
– PM-1: Guideline-Directed Medical Therapy (GDMT) at Discharge – Initiate optimal GDMT in hospitalized heart failure patients before discharge.
– PM-2: Blood Pressure Control in HFpEF – Ensure optimal blood pressure control in patients with heart failure with preserved ejection fraction (HFpEF).
– PM-3: SGLT2 Inhibitor Use in HFrEF – Prescribe sodium-glucose cotransporter-2 inhibitors for patients with heart failure with reduced ejection fraction (HFrEF).
2 – Quality Measures (QM):
– QM-1: SGLT2 Inhibitor in HFmrEF or HFpEF – Recommend SGLT2 inhibitors for patients with mildly reduced or preserved ejection fraction.
– QM-2: Social Determinants of Health – Screen and document actions addressing social determinants of health for heart failure patients.
– QM-3: Pregnancy Counseling – Provide patient-centered counseling on contraception and pregnancy risks for individuals with cardiomyopathy.
– QM-4: Continuation of GDMT in HFimpEF – Continue GDMT in patients with heart failure with improved ejection fraction (HFimpEF).
– QM-5: Optimization of GDMT before TEER – Optimize GDMT before performing transcatheter edge-to-edge repair (TEER) for chronic secondary severe mitral regurgitation.
– QM-6: Monoclonal Protein Screening for Cardiac Amyloidosis – Ensure monoclonal protein screening in patients undergoing bone scintigraphy for suspected transthyretin cardiac amyloidosis.
3 – Emphasis on Multidisciplinary Care: The guidelines highlight the importance of addressing cardiovascular disease risks, social determinants of health, and providing comprehensive patient education, particularly concerning reproductive health in women with cardiomyopathy.
4 – Exclusions: The measures exclude patients after heart transplantation or left ventricular assist device placement and allow for patient-specific exclusions when treatment is not appropriate based on clinical evidence or patient preference.
5 – No Retired Measures: The update did not retire any measures from the 2020 set, reflecting their continued relevance.
Conclusion:
The 2024 update introduces critical new performance and quality measures that reflect the latest evidence in heart failure management. These measures aim to improve patient outcomes by emphasizing guideline-directed therapies, multidisciplinary care, and consideration of social and health determinants.
Guideline Reference:
New AHA Guidelines for Managing Elevated Blood Pressure in Acute Care Settings – Hypertension
13 Aug, 2024 | 13:13h | UTCIntroduction:
The American Heart Association (AHA) has released a scientific statement focusing on the management of elevated blood pressure (BP) in acute care settings. This guideline addresses the significant variation in practice due to a lack of robust evidence for managing BP in such environments, particularly in emergencies or when elevated BP is asymptomatic.
Key Points:
1 – Classification of Elevated BP: Elevated BP in acute care settings is categorized into asymptomatic elevated BP and hypertensive emergency, the latter requiring immediate treatment due to acute target-organ damage.
2 – Hypertensive Emergency: Immediate treatment is necessary for patients with BP >180/110–120 mm Hg and evidence of new or worsening target-organ damage, typically using intravenous antihypertensive medications in a closely monitored environment.
3 – Asymptomatic Elevated BP: In cases where elevated BP is present without symptoms or target-organ damage, the use of antihypertensive medications should be approached cautiously. Recent studies suggest potential harm from aggressive treatment, highlighting the importance of verifying BP readings and identifying reversible causes before intervention.
4 – Proper BP Measurement: Accurate BP measurement is crucial. The guidelines stress using recently calibrated devices and following correct measurement techniques to avoid unnecessary treatment due to erroneous readings.
5 – PRN Orders: The use of “as needed” (PRN) antihypertensive medications for asymptomatic elevated BP is discouraged due to the risks of overtreatment and variability in BP control, which can lead to adverse outcomes.
6 – Treatment Thresholds: The guidelines recommend a high threshold for initiating or intensifying antihypertensive treatment in asymptomatic patients, emphasizing the need for repeated measurements and assessment of underlying causes.
7 – Post-Discharge Care: It is crucial to maintain prehospital antihypertensive regimens and avoid intensification at discharge unless clearly indicated. Effective care coordination and patient education are vital for successful transitions from hospital to home care.
Conclusion:
These guidelines represent a significant step toward standardizing BP management in acute care settings. By focusing on accurate measurement, cautious treatment of asymptomatic elevated BP, and proper follow-up, clinicians can reduce unnecessary interventions and improve patient outcomes.
Guideline Reference: Bress, A.P., et al. (2024). “The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement from the American Heart Association.” Hypertension, 81–e106.
IDSA 2024 Guidelines for Managing Complicated Intra-abdominal Infections – Clin Infect Dis
10 Aug, 2024 | 22:10h | UTCIntroduction: The Infectious Diseases Society of America (IDSA) has updated its clinical practice guidelines for managing complicated intra-abdominal infections in adults, children, and pregnant individuals. The update focuses on risk assessment, diagnostic imaging, and microbiological evaluation, with recommendations grounded in systematic literature reviews and the GRADE approach for rating evidence.
Key Points:
1 – Risk Stratification:
– For adults with complicated intra-abdominal infections, the APACHE II score is recommended for risk stratification within 24 hours of hospital or ICU admission. The WSES Sepsis Severity Score is an acceptable alternative.
– No specific severity scoring system is recommended for pediatric patients.
2 – Diagnostic Imaging for Appendicitis:
– In non-pregnant adults, CT is suggested as the initial imaging modality for suspected acute appendicitis.
– For children, an abdominal ultrasound (US) is preferred initially, with MRI or CT recommended if the US is inconclusive.
– In pregnant individuals, US or MRI can be considered, with MRI suggested if initial US results are inconclusive.
3 – Imaging for Acute Cholecystitis and Cholangitis:
– For non-pregnant adults, US is recommended initially. If inconclusive, a CT scan is suggested.
– For pregnant individuals, US or MRI can be used, but the guidelines do not specify a preferred modality due to a knowledge gap.
4 – Blood Cultures:
– Blood cultures are recommended in adults and children with suspected intra-abdominal infections presenting with severe symptoms such as hypotension or tachypnea, especially when antibiotic-resistant organisms are a concern.
– Routine blood cultures are not recommended for patients without these risk factors.
5 – Intra-abdominal Fluid Cultures:
– In complicated intra-abdominal infections requiring source control procedures, obtaining intra-abdominal cultures is advised to guide antimicrobial therapy.
– In uncomplicated appendicitis cases, routine cultures are not recommended unless the patient is immunocompromised or complicated disease is suspected during surgery.
Conclusion: These guidelines provide evidence-based recommendations to improve the management of complicated intra-abdominal infections, emphasizing appropriate risk stratification, targeted diagnostic imaging, and the selective use of cultures to guide therapy.
Consensus Recommendations: Cardiovascular Risks in People With Narcolepsy – J Am Hear Assoc
10 Aug, 2024 | 21:48h | UTCIntroduction: The Journal of the American Heart Association recently published a consensus guideline by a panel of sleep and cardiology experts to address the heightened cardiovascular risks in individuals with narcolepsy. Given the increased prevalence of hypertension and cardiometabolic comorbidities in this population, the panel developed recommendations aimed at mitigating these risks.
Key Points:
1 – Increased Cardiovascular Risk in Narcolepsy:
– Individuals with narcolepsy, both Type 1 (NT1) and Type 2 (NT2), exhibit higher rates of cardiovascular and cardiometabolic diseases, such as hypertension, obesity, and diabetes, compared to the general population.
– The association of narcolepsy with conditions like obstructive sleep apnea (OSA) and restless legs syndrome further elevates cardiovascular risk.
2 – Monitoring and Early Detection:
– Clinicians should annually monitor blood pressure, weight, and waist circumference in patients with narcolepsy, even in the absence of existing cardiovascular disease.
– Screening for lipid levels and hemoglobin A1c is recommended, especially in patients with risk factors like hypertension, obesity, and diabetes.
3 – Lifestyle and Therapeutic Interventions:
– Patients should be educated about the link between narcolepsy and cardiovascular disease. Emphasis should be placed on maintaining optimal sleep duration, regular exercise, healthy eating, and reducing sodium intake.
– The American Heart Association’s “Life’s Essential 8” guidelines should be followed to enhance overall cardiovascular health.
4 – Medication Management:
– Narcolepsy medications, particularly stimulants and sodium oxybate, can increase cardiovascular risk. Clinicians should consider the patient’s cardiovascular profile when prescribing these treatments and explore alternatives with lower cardiovascular impact if necessary.
5 – Sodium Reduction:
– High sodium intake, from both diet and certain narcolepsy medications, is associated with increased blood pressure and cardiovascular disease. Patients should be advised to reduce sodium intake, and clinicians should consider prescribing lower-sodium alternatives when possible.
Conclusion: These expert consensus recommendations underscore the importance of proactive cardiovascular risk management in patients with narcolepsy. By implementing these guidelines, clinicians can help mitigate the long-term cardiovascular risks associated with this chronic sleep disorder.
IDSA 2024 Guidelines for Treatment of Antimicrobial-Resistant Gram-Negative Infections – Clin Infect Dis
10 Aug, 2024 | 20:16h | UTCIntroduction:
The Infectious Diseases Society of America (IDSA) has released updated guidelines in 2024 addressing the treatment of infections caused by antimicrobial-resistant (AMR) Gram-negative bacteria. These guidelines cover pathogens including extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E), AmpC β-lactamase-producing Enterobacterales (AmpC-E), carbapenem-resistant Enterobacterales (CRE), difficult-to-treat Pseudomonas aeruginosa (DTR P. aeruginosa), carbapenem-resistant Acinetobacter baumannii (CRAB), and Stenotrophomonas maltophilia.
Key Points:
1 – ESBL-E Infections:
– Preferred treatment for uncomplicated cystitis includes nitrofurantoin and TMP-SMX. Fluoroquinolones and carbapenems are alternatives but should be reserved to prevent resistance.
– For pyelonephritis or complicated urinary tract infections (cUTI), TMP-SMX, ciprofloxacin, or levofloxacin are preferred. Carbapenems are recommended when resistance precludes other options.
2 – AmpC-E Infections:
– Cefepime is suggested for treating infections caused by organisms at moderate risk of significant AmpC production (e.g., Enterobacter cloacae complex, Klebsiella aerogenes, and Citrobacter freundii).
– The use of cephamycins (e.g., cefoxitin, cefotetan) for treating ESBL-E infections is not recommended due to insufficient clinical outcome data.
3 – CRE Infections:
– Acknowledgement of increased prevalence of metallo-beta-lactamase (MBL)-producing CRE in the U.S.
– The combination of ceftazidime-avibactam and aztreonam is suggested for MBL-producing CRE, with updated dosing recommendations provided.
4 – DTR Pseudomonas aeruginosa:
– Traditional β-lactams (e.g., cefepime) with high-dose extended-infusion therapy are recommended.
– Tobramycin or amikacin, administered once daily, are alternatives for pyelonephritis or cUTI.
5 – CRAB and Stenotrophomonas maltophilia Infections:
– Sulbactam-durlobactam with meropenem or imipenem-cilastatin is the preferred treatment for CRAB.
– The order of preference for agents treating S. maltophilia includes cefiderocol, ceftazidime-avibactam, and aztreonam, among others.
Conclusion:
The 2024 IDSA guidelines provide critical updates on managing AMR Gram-negative infections, emphasizing the importance of selecting the appropriate antibiotic based on susceptibility, resistance mechanisms, and patient-specific factors. These guidelines are essential for optimizing treatment outcomes in the face of increasing antimicrobial resistance.
Reference:
New Guidelines Recommend Against Routine Vitamin D Testing and Treatment for Healthy Adults – J Clin Endocrinol Metab
4 Aug, 2024 | 19:19h | UTCIntroduction: The Endocrine Society has developed new clinical practice guidelines focused on the use of vitamin D for the prevention of various diseases. These guidelines were created by a multidisciplinary panel, including experts in adult and pediatric endocrinology, internal medicine, obstetrics and gynecology, nutrition, and epidemiology.
Key Points:
1 – Empiric Vitamin D Supplementation in Children and Adolescents:
– Recommended to prevent nutritional rickets.
– May lower the risk of respiratory tract infections.
– Dosage in trials ranged from 300 to 2000 IU daily, with an average of about 1200 IU per day.
2 – Empiric Vitamin D Supplementation or Testing in Adults Under 75:
– Not recommended for generally healthy adults without specific indications.
3 – Empiric Vitamin D Supplementation in Adults Over 75:
– Suggested due to its potential to lower the risk of mortality.
– Treatment should be empirical, no testing recommended if there are no established indications for testing (e.g., hypocalcemia).
– Recommended daily rather than intermittent high doses. Dosage in clinical trials ranged from 400 to 3333 IU daily equivalent.
4 – Vitamin D Supplementation During Pregnancy:
– Suggested to lower the risk of preeclampsia, intrauterine mortality, preterm birth, small-for-gestational-age birth, and neonatal mortality.
– Empiric supplementation recommended without routine 25(OH)D testing unless there are established indications for testing.
– Dosages in trials ranged from 600 to 5000 IU daily equivalent, with an average of about 2500 IU per day.
5 – Vitamin D and High-Risk Prediabetes:
– Suggested to reduce the progression to diabetes.
– In clinical trials, vitamin D dosages ranged from 842 to 7543 IU daily. The estimated weighted average was approximately 3500 IU per day.
6 – Routine 25(OH)D Testing:
– Not recommended for the general population, including those with obesity or dark complexion.
– No clear evidence defining optimal target levels for disease prevention.
Conclusion: These guidelines emphasize the importance of targeted vitamin D supplementation for specific age groups and conditions, while advising against routine testing for vitamin D levels in the general population. Empiric supplementation is considered beneficial, particularly in children, pregnant women, and older adults, and is feasible, cost-effective, and generally acceptable.