update in outpatient medicine 2017 - the hindson foundation · •overweight & obese + low...

UPDATE IN OUTPATIENT MEDICINE

2017 Neil Argyle, MD, MPH

Associate Chief of Staff for Education

VISN 20 Academic Affiliations Officer

Boise VAMC

DISCLOSURES

• I have no relationships with any entity producing,

marketing, re-selling, or distributing health care

goods or services consumed by or used on

patients.

• I’m a Chicago Cubs fan, and I truly believe this

will be “our” year… again… Go Cubs!

• I’ll be using Poll Everywhere today, use your

phone, go to: PollEv.com/NEILARGYLE251 to

access polls for today, or text neilargyle 251 to

37607 to join the session, then text your answer.

https://pollev.com/NEILARGYLE251

OBJECTIVES

• Update on Literature published in the last year

• Change the way you practice medicine

• Introduce you to emerging EBM

• Keep you awake

• Not embarrass myself

CASE 1: MS. LOE IRONS

• Ms. Irons is a 40 yo woman who presents to your office for

routine follow-up. She states she maybe has a little bit of low

energy, but overall is doing quite well.

• PE: unremarkable

• VS: normal

• Labs: low normal Hgb/Hct, TSH: WNL, FT4: WNL, Iron: low, Iron

saturation: low, TIBC: high.


• What do you do next?

• A: Start her on Ferrous Sulfate three times daily

• B: Start her on Ferrous Sulfate twice daily

• C: Start her on Ferrous Sulfate once daily

• D: Start her on Ferrous Sulfate once, every other day

• E: Give her an infusion of Iron Dextran in the infusion clinic

• F: Tell her to suck it up, check her labs in a few months, and

if her Hgb/Hct fall out of the normal range, then consider

doing something… but in the mean time, she should eat a

steak… yum… steak.


• What do you do next?

• A: Start her on Ferrous Sulfate three times daily

• B: Start her on Ferrous Sulfate twice daily

• C: Start her on Ferrous Sulfate once daily

• D: Start her on Ferrous Sulfate once, every other day

• E: Give her an infusion of Iron Dextran in the infusion clinic

• F: Tell her to suck it up, check her labs in a few months, and

if her Hgb/Hct fall out of the normal range, then consider

doing something… but in the mean time, she should eat a

steak … yum… steak.

PATHOPHYSIOLOGY

• Daily iron supplements, in single doses or divided doses increases

serum hepcidin and thus reduces iron absorption and iron levels.

• Hepcidin, a protein, synthesized in the liver, normally reduces

extracellular iron in the body

• Lowers dietary iron absorption by reducing gut absorption

• Reduces iron exit from macrophages (where iron is stored)

• Reduces iron exit from liver

• (Works on the transmembrane iron transporter: ferroportin)

• Alternate day dosing optimizes iron absorption

PATHOPHYSIOLOGY

STATISTICS

• Study 1: (P = 0.0013) Statistically significant difference, 60 mg FeSO4

• Group 1: consecutive day dosing:

• Fractional iron absorption: 16.3%, total 131.0 mg absorbed

• Hepcidin higher in this group (P = 0.0031)

• Group 2: alternate day dosing:

• Fractional iron absorption: 21.8% (P = 0.0013)

• total 175.3 mg absorbed (P = 0.0010)

• Study 2: (P = 0.33) No difference between groups, 120 mg total iron administered

• Group 1: once daily dosing, Iron absorption: 11.8%, total 44.3 mg absorbed

• Group 2: twice daily dosing, Iron absorption: 13.1%, total 49.4 mg absorbed

• Serum hepcidin higher in twice daily than once daily dosing (P = 0.013)

TAKE HOME POINT

• Every other day dosing of iron appears to be more effective to replete

iron stores than standard daily or multiple-doses per day.

CASE 2: MR. FIT NESS • Mr. Ness, a 60 yo M, telemetry nurse, presents to your office for routine

follow-up. You had seen him last year and had a long discussion about

how using a Fit-Bit doesn’t actually help people lose weight. He

presents again to discuss his overall health.

• PMH: IFG, HTN, HLD, obesity

• VS: BMI of 30, afebrile, RR 20, HR 80, BP 130/80, sat 97% on RA

• Meds: metformin, Lisinopril, atorvastatin

CASE 2: MR. FIT NESS

• What do you tell him to do?

• A: If you don’t have time during the week, exercise on the

weekend.

• B: Get out and get active, it will reduce your risk of heart

disease, regardless of your BMI

• C: Take 15 min walks after eating to help improve your

blood sugars

• D: Exercise is good for your heart, more is better,

vigorous is best

• E: All of the above

LITERATURE

WEEKEND WARRIORS

• 63,591 adults, mean age of 58.6 years

• Compared

• Inactive: no moderate intensity activity

• Insufficiently active: (< 150 min per week of moderate intensity with

< 75 min/wk of intense activity)

• Weekend warrior: > 150 min/wk in mod intensity or > 75 min/wk

intense activity in 1-2 sessions)

• Regularly active: > 150 min/wk in mod intensity or > 75 min/wk

intense in >3 sessions

• Outcomes: all cause, CVD, and cancer mortality

WEEKEND WARRIORS

• 1-2 sessions per week of moderate to vigorous intensity physical

activity may be sufficient to reduce risks for all-cause, CVD, and cancer

mortality.

LITERATURE REVIEW

BMI AND ACTIVITY

• 5344 patients, 55 years and older, 15 years of follow-up

• 866 experienced a CV event

• Overweight & obese + low physical activity

• Higher CVD risk than normal weight participants with

high physical activity.

• Overweight and obese with HIGH physical activity

• CVD risk NOT increased

• (HR 1.03 CI: 0.82-1.29, and HR 1.12 CI 0.83-1.52)

• Beneficial impact of physical activity on CVD might

outweigh the negative impact of body mass index.

DIABETIC WALKS

DIABETIC WALKS • Inactive older adults, non-smoking

• IFG between 105-125

• 3 random exercise protocols, 4 weeks apart

• 48 hour stay in observed room

• Day 1 was control

• Day 2 was intervention

• Post meal walking for 15 min or 45 min of sustained walking at 1030 am or 430 pm

• Walking done on treadmill, with absolute intensity of 3 METs

• Continuous glucose monitoring

• Sustained morning walking and post-meal walking significantly improved 24 hour glycemic

control when compared to control day

• Post-meal walking was significantly (P<0.01) more effective than 45 min of sustained morning or

afternoon walking in lowering 3 hour post-dinner glucose

ACTIVITY / INTENSITY / DEATH

ACTIVITY / INTENSITY / DEATH

• Lower all-cause mortality HR: 0.90 [ 0.87 – 0.93 ], steeper at lower vs higher exercise

• Lower CV mortality HR: 0.92 [ 0.88- 0.96 ]

TAKE HOME POINTS

• 1-2 sessions per week of mod/high intensity exercise reduces risks for

all-cause, CVD, and cancer mortality.

• Positive impact of exercise on CVD might outweigh the negative

impact of elevated BMI on middle-aged / elderly patients.

• 15 min walks three times a day after eating is an effective way to

control post-prandial hyperglycemia in older patients.

• Exercise is good for your heart, more is better, vigorous is best

CASE 3: MS. CHLOE STRIDIA

• Ms. Stridia is a 58 yo W, who presents after recent dental

abscess, for which she received amoxicillin/clavulanate.

• Dental issues are resolving; however, following the

antibiotics she developed a severe, foul-smelling

diarrhea & presented to the ER.

• She was admitted for recurrent c. difficile, treated with

vancomycin, and her diarrhea resolved.

• This was her third recurrence of c. diff.

• VS: HR 80, BP 160/88, RR 18, Temp 38 C, sat 98% on RA

• Labs: All WNL


• What do you tell her now?

• A: Never take antibiotics again

• B: You should only take an antibiotic when taking a probiotic as well

• C: At her next recurrence, start her on fidaxomicin (instead of

vancomycin) to reduce risk of recurrence

• D: Start her on Bezlotoxumab to reduce risk of RCDI while on

vancomycin at her next recurrence.

• E: Consult GI for a colonoscopy delivered fecal microbiota transplant

• F: Consult GI for endoscopically delivered fecal microbiota

transplant

• G: Prescribe fecal microbiota transplant in a capsule regimen

C-DIFF POLLEV SLIDE HERE


• What do you tell her now?

• A: Never take antibiotics again

• B: You should only take an antibiotic when taking a probiotic as well

• C: At her next recurrence, start her on fidaxomicin (instead of

vancomycin) to reduce risk of recurrence

• D: Start her on Bezlotoxumab to reduce risk of RCDI while on

vancomycin at her next recurrence.

• E: Consult GI for a colonoscopy delivered fecal microbiota transplant

• F: Consult GI for endoscopically delivered fecal microbiota

transplant

• G: Prescribe fecal microbiota transplant in a capsule regimen

LITERATURE

LITERATURE

• Non-inferiority: 116 patients, 57 capsule 59 colonoscopy

• Given the same amount of “donor stool” in each method

• Colonoscopy: 360 ml of fecal slurry in the cecum

• Capsule: 40 capsules under DOT

• 10+ days of vancomycin for symptom resolution, then treated with BID dosing of

vancomycin twice daily until 24 hours prior to FMT

• 4L GoLYTELY the night before FMT

• Prevention of RCDI after a single treatment was 96.2% in both arms

• A significantly greater proportion of participants receiving capsules rated their

experience as “not at all unpleasant” (66% vs 44%, P =0.01)

TAKE HOME POINT

• Oral capsule administration of FMT is as efficacious as colonoscopy delivery

• More efficacious than endoscopy

• Higher dose used in this study

• Bowel prep used prior to administration

• Could also consider the use of the following alternative regimens:

• Fidaxomicin (instead of vancomycin)

• Shown to reduce risk of recurrence compared to vancomycin

• Bezlotoxumab and Vancomycin reduces the risk of RCDI

CASE 4: MR. KID KNEIGH

• Mr. Kneigh is a 65 yo M, who presents for evaluation of non-specific

chest pain of several weeks duration. His ECG does not show any

evidence of ischemia at rest. He had a negative stress-echo a month

ago. After discussion with cardiology it is determined he should

undergo angiography.

• PMH: Diabetes, HLD, HTN, possible TIA, Stage III CKD, Tobacco use.

• VS: HR 95, RR 20, BP 155/85, Sat: 94% on RA

• Labs: Creatinine of 1.5, eGFR of 30, A1c: 7.2, Lipids WNL, CBC WNL

CASE 4: MR. KID KNEIGH

• What do you do now?

• A: Non-contrasted CT scan of heart

• B: Pre-hydrate with normal saline, then proceed with contrasted CTA

• C: Use sodium bicarbonate / NAC and fluids, then proceed with contrasted CTA

• D. Obtain an MRI of the heart with gadolinium

• E: Obtain an MRI of the heart without contrast

• F: You don’t need the study, modern clinicians rely too much on imaging anyway… be like

the ol’ country doc and perform a better physical exam

LITERATURE

LITERATURE

• 2 by 2 factorial design, 4993 participants in the intention to treat analysis

• Randomly assigned 5177 patients with stage III and IV CKD

• IV 1.26% sodium bicarbonate or IV 0.9% NS AND 5 days of NAC or placebo

• Primary end point: composite of death, dialysis, increase in creatinine

• Secondary end points:

• Contrast associated AKI, Death at 90 days, Dialysis at 90 days

• Persistent kidney impairment at 90 days

• Hospitalization for ACS, Heart failure, or stroke at 90 days

• All cause hospitalization at 90 days

• Trial stopped after prespecified interim analysis

LITERATURE

LITERATURE

• Primary end point of death: NO SIGNIFICANT BETWEEN-GROUP DIFFERENCES

• 110/2511 in sodium bicarb group

• 116/2482 in sodium chloride group

• 114/2495 in N-acetylcysteine group

• 112/2498 in the placebo group

• Secondary end point AKI: NO SIGNIFICANT BETWEEN-GROUP DIFFERENCES

• 239/2511 in sodium bicarb group

• 206/2482 in sodium chloride group

• 228/2495 in N-acetylcysteine group

• 217/2498 in the placebo group

TAKE HOME POINT

• Among patients with Stage 3 and 4 CKD, who will undergo angiography,

• There was no benefit for using sodium bicarbonate over IV normal saline.

• There was no benefit for using oral NAC over placebo.

• No benefit for:

• Death

• Dialysis

• Persistent kidney dysfunction

• Prevention of contrast associated AKI

CASE 5: MR. LUM BAUGHGO

• 68 yo M with HTN, HLD, depression, presents for low back pain. This has been a

chronic issue for him, with acute exacerbations intermittently. No bowel or bladder

incontinence.

• PMH: DM, HTN, HLD, obesity.

• Exam: 5/5 strength BLE, limited by pain, confined to his lower back bilaterally.

• X-rays: unremarkable

• MRI: (had already been undertaken by his outside provider). Mild central lumbar

spinal stenosis (LSS) L2-3, L3-4, no spondylolisthesis, mild right sided foraminal

stenosis at same levels.

CASE 5: MR. LUM BAUGHGO

• What do you do for Mr. Baughgo?

• A: Give him scheduled acetaminophen for the pain

• B: Give him scheduled NSAIDs for the pain

• C: Give him scheduled gabapentinoid (gabapentin/pregabalin) for the pain

• D: Start him on low dose narcotics, with a gradual titration up to effective dose

• E: Send him for some PT with some mindfulness based stress reduction

Just Kidding

CASE 5: MR. MR. LUM BAUGHGO

• What do you do for Mr. Baughgo?

• A: Give him scheduled acetaminophen for the pain

• B: Give him scheduled NSAIDs for the pain

• C: Give him scheduled gabapentinoid (gabapentin/pregabalin) for the pain

• D: Start him on low dose narcotics, with a gradual titration up to effective dose

• E: Send him for some PT with some mindfulness based stress reduction

LITERATURE

LITERATURE

• Acetaminophen: 13 trials

• Ineffective for reducing pain intensity, disability, or improving quality of life

• Nearly 4 times as likely to have abnormal results on LFT

• Minimal short term benefit for pain

• Results support reconsideration of recommendations to sue acetaminophen for patients

with lower back pain

LITERATURE

• Gabapentin vs. Placebo:

• Minimal improvement in pain

• Pregabalin vs. other analgesic group

• Greater improvement in the “other” analgesic group

• Side effects more common with gabapentin than placebo

• Dizziness, fatigue, difficulties with mentation, visual disturbances

LITERATURE: GUIDELINE

• Most with acute or subacute low back pain improve over time regardless of

treatment:

• Heat, massage, acupuncture, spinal manipulation (low)

• NSAIDS or muscle relaxants (moderate evidence)

• Chronic low back pain: initial treatment should include: (strong recommendation)

• Exercise, multi-disciplinary rehabilitation, acupuncture, mindfulness-based stress

reduction

• Chronic low back pain: inadequate response to non-pharmacologic therapy

• NSAIDs first line

• Tramadol or duloxetine as second line

• Opioids if all other modalities have failed (weak recommendation)

REFERENCES:

• Iron Absorption from oral iron supplements given on consecutive versus alternate days

and as single morning doses versus twice-daily split dosing in iron depleted women: two

open label, randomized trials. Stoffel NU, et al. Lancet haematol. 2017 Nov:4(11):e524-

e533. Epub 2017 Oct. 9

• Effect of Oral Capsule – vs Colonoscopy-Delivered Fecal Microbiota Transplantation on

Recurrent Clostridium difficile infection. Kao, D, et al. JAMA. 2017;318(20):1985-1993.

• Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal

pain and osteoarthritis: systematic review and meta-analysis of randomised placebo

controlled trials. The BMJ. 2015;350:h1225. doi:10.1136/bmj.h1225.

QUESTIONS?

update in outpatient medicine 2017 - the hindson foundation · •overweight & obese + low...

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