Drugs and AAFP

DYSLIPIDEMIA •    Lots of patients are asking if they should stop taking niacin (Niaspan, etc) for dyslipidemia. 

   It's all due to the new study showing that adding niacin to a statin does NOT improve cardiovascular outcomes...and might increase strokes.    This is a surprise.    We're accustomed to adding niacin to a statin to raise HDL...and further lower LDL and triglycerides.    But this might not be helping as much as we thought.    Adding niacin doesn't seem to improve OUTCOMES...in patients with heart disease and an LDL already treated to 70 mg/dL.    Some experts say this study shows that LDL trumps HDL.    Others say this is further evidence of the possible benefit of statins' non-lipid-lowering effects.    But...and it's a big but...this doesn't tell us whether niacin is beneficial for the many patients who are NOT at their LDL goal.    Stick with the current guidelines and focus on lowering LDL.    Emphasize a healthy diet and regular physical activity.    Maximize statins first...they have the best evidence for reducing mortality and cardiac risk.    But don't use simvastatin 80 mg/day...myopathy risk is too high. If simvastatin (Zocor, etc) 40 mg isn't enough, go to atorvastatin (Lipitor) 40 mg or rosuvastatin (Crestor) 10 to 20 mg.    If patients can't reach their LDL goal on a statin alone, discuss the pros and cons of adding niacin, ezetimibe (Zetia), or a bile acid sequestrant.    Explain that combo therapy lowers LDL more. But the cons are the extra cost...potential adverse effects...and lack of good evidence that the combos improve outcomes.    Don't jump to conclusions about niacin and strokes. Niacin has been around a long time...and has never been linked to strokes.

DIABETES •    Some people are confusing the news about Avandia and Actos. 

   Avandia products will all but disappear...due to cardiac concerns.    After November 18th, prescribers and patients will have to be enrolled in theAvandia-Rosiglitazone Medicines Access Program to prescribe or get rosiglitazone.    Patients will qualify only if they're already on rosiglitazone...or can't use other diabetes meds, including pioglitazone (Actos, etc).    Retail pharmacies will no longer carry rosiglitazone...patients will have to get it by mail from a specialty pharmacy.    Switch any patients still on rosiglitazone to another med.    The Actos situation is different. Pioglitazone sales are being suspended in France and Germany...and scrutinized here...due to concerns about bladder cancer.    But it's premature to abandon pioglitazone.    Any risk is very small...possibly 3 extra cases of bladder cancer for every 10,000 patients per year on pioglitazone long-term.    For now, discuss this possible risk with patients...and don't use pioglitazone in patients who have or had bladder cancer.

ANTIDEPRESSANTS •    You'll see Viibryd (VI-brid) marketed as a new "dual-acting" serotonergic

antidepressant.    Viibryd (vilazodone) inhibits serotonin reuptake like SSRIs...plus it's also a partial serotonin agonist.    The company hoped Viibryd would be more effective than SSRIs.    But it's not.    Viibryd doesn't work better than fluoxetine or citalopram...and it causes more GI side effects.    You might also hear that Viibryd has a low risk of sexual side effects...but it's too soon to tell if this is true.    Viibryd comes in a starter kit to help minimize GI problems. If you start a patient on Viibryd, give 10 mg/day for 7 days...20 mg/day for 7 days...then 40 mg/day thereafter.    Don't exceed 20 mg/day if patients are taking a strong CYP3A4 inhibitor...ketoconazole, clarithromycin, ritonavir, etc.    Tell patients to take Viibryd with food for adequate absorption...and caution about possible nausea, diarrhea, insomnia, and dizziness.    Viibryd will cost $150 per month. Continue to use an SSRI or SNRI first for depression.

Singular• Patients are hearing that Singulair is "as good as" inhaled corticosteroids or long-acting beta-

agonists for asthma.   This comes from a new study that suggests leukotriene antagonists are "essentially equivalent" to using an inhaled steroid first...or to adding a long-acting beta-agonist second in adults.   Now some patients are hoping to replace a twice-daily inhaler with a once-daily pill. Plus, Singulair will be generic next year.   Help patients put the new info in perspective.   A leukotriene antagonist seems to work as well to improve quality of life after two MONTHS...but not necessarily after two YEARS.   Continue to start with an inhaled steroid for persistent asthma in MOST patients. These have the most evidence for improving outcomes.   Emphasize adherence. Advise patients that inhaled steroids need to be used regularly to prevent exacerbations.   If a low-dose inhaled steroid isn't enough, increase the steroid dose...or add a long-acting beta-agonist. In kids, also consider adding Singulair (montelukast)...it has anti-inflammatory effects and symptoms in kids are often due to inflammation.   Save leukotriene antagonists as monotherapy for patients who have trouble using or adhering to inhaled steroids

RESPIRATORY / ALLERGY•     You'll hear about Daliresp (DA-li-resp), a new oral tablet for severe COPD in patients

with chronic bronchitis.    Daliresp (roflumilast) is the first in a new class of oral phosphodiesterase 4 inhibitors. It works by reducing lung inflammation.    It's added to the usual bronchodilator therapy to decrease exacerbations...but only for severe, chronic COPD.    That's because the modest benefit may not outweigh its risks.    Daliresp is linked to insomnia, weight loss, depression, and possibly suicide. There's also concern about a possible increased cancer risk...but tell patients this hasn't been proven.    Daliresp 500 mcg/day costs about $200 per month.    Maximize bronchodilators before trying Daliresp.    Watch for interactions with CYP3A4 drugs. CYP3A4 inhibitors (erythromycin, etc) increase Daliresp levels and can increase adverse effects. Strong CYP3A4 inducers (phenytoin, etc) can decrease efficacy.    Caution patients about possible GI side effects...diarrhea, nausea, abdominal pain, etc...especially in the first few weeks.    Warn them to report serious mood or behavioral changes.

CLOSTRIDIUM DIFFICILE DIARRHEA•    Reps will promote that the new oral drug Dificid (fidaxomicin) for Clostridium

difficile diarrhea is superior to oral vancomycin.    That's because Dificid works at least as well as vanco to control C. diff...but seems to have a lower risk of recurrence.    There's one less recurrence within one month for every 10 patients treated with Dificid instead of oral vancomycin.    But recurrence rates are similar if patients have the more virulent strain of C. diff. About one-third of cases in the U.S. are now caused by this BI/NAP1/027 strain.    Dificid costs about $2800 for a standard 10-day course.    Vancomycin 125 mg QID for 10 days costs about $1300 for the capsules...and $60 or less if you give the injectable orally.    Continue to use oral metronidazole 500 mg TID for 10 to 14 days for mild to moderate infections...and oral vancomycin 125 mg QID for 10 to 14 days for severe infections.    Consider using Dificid 200 mg twice daily for 10 days to minimize recurrence risk...or if fewer doses will improve adherence.    Emphasize the importance of handwashing with soap and water. Explain that alcohol gels don't kill C. diff spores.

RESTLESS LEGS SYNDROME •   You'll hear reps talking about Horizant for restless legs syndrome. 

   It's an extended-release version of gabapentin enacarbil...which is converted to plain gabapentin in the body. This formulation increases and prolongs its absorption.    But there's no evidence it works better or is better tolerated. And it costs about $120 a month...compared to $6 to $95 for gabapentin.    Consider Rx meds for patients who need them for restless legs.    Dopamine agonists (pramipexole, ropinirole) are often tried first for daily symptoms.    Tell patients to take them about 2 hours before bedtime...but caution about nausea, dizziness, sleepiness, and impulse control problems such as compulsive gambling or shopping.    Give half the dose earlier if symptoms worsen or occur earlier.    Carbidopa/levodopa can help with intermittent symptoms. Have patients take one-half or one 25/100 mg tab before bedtime...or a 25/100 mg CR tab if the effects wear off before morning.    Gabapentin can help patients who don't tolerate dopamine agonists...or whose symptoms include pain or unpleasant sensations.    Start with gabapentin 100 to 300 mg up to two hours before bedtime...titrating up to about 1800 mg/day if needed.    For doses over 600 mg/day, have patients take half the dose in the late afternoon and the rest up to 2 hours before bedtime.    Horizant dosing is different...give 600 mg at 5 PM with food.    Keep in mind that Horizant and gabapentin dosing is not equivalent. Retitrate doses if you need to switch.

Positive-pressure ventilation is not necessary in the first _______

of cardiac arrest. A) 2 to 4 min B) 5 to 7 min

 C) 10 to 12 min D) 15 to 17 min

Answer

•  C) 10 to 12 min

Which of the following drugs have been proven effective in the

management of cardiac arrest? A) Vasopressors

 B) Antiarrhythmics C) Amiodarone

 D) None of the above

Answer

•  D) None of the above

The "4 Cs" of modern management of cardiac arrest include which of the following?Cardiac

compressionsCardioversion

CoolingCardiac catheterization

Calcium

 A) 1,2,3,4 B) 1,2,4,5 C) 1,3,4,5 D) 1,2,3,5

Answer

• Cardiac compressions

• Cardioversion

• Cooling

• Cardiac catheterization

Most cases of unstable bradycardia are not related to acute myocardial infarction.

 A) True B) False

Answer

•  A) True

Electrocardiographic findings of hyperkalemia include which of

the following? A) Peaked T wave

 B) Widening of QRS complex C) Flattening and eventual loss

of P wave D) All the above

Answer

• D) All the above

Which of the following statements about adenosine is correct?

 A) All patients with supraventricular tachycardia (SVT) respond to adenosine B) Less than 50% of patients with VT

respond to adenosine C) Most patients with adenosine-sensitive VT

do not have underlying cardiac disease D) Adenosine is reliable for distinguishing

VT from SVT

Answer

• C) Most patients with adenosine-sensitive VT do not have underlying cardiac disease

Accelerated idioventricular rhythm does not generally require

treatment. A) True B) False

Answer

•  A) True

 All the following statements about amiodarone are true,except:

 A) Effective for premature ventricular contractions

 B) Contraindicated in pregnancy C) Shortens QT interval

 D) Efficacy for treatment of stable VT approximately equal to

that of lidocaine

Answer

• C) Shortens QT interval

Which of the following has been shown to be more sensitive than

common sense in predicting which patients with syncope will have serious adverse outcomes?

 A) Boston Syncope Criteria B) Short-Term Prognosis of

Syncope (StePS) study C) San Francisco Syncope Rule

 D) None of the above

Answer

•  D) None of the above

Patients who have taken clopidogrel within _______ of coronary bypass

surgery are at risk for increased bleeding complications, increased need for packed cell transfusions,

and increased perioperative mortality. A) 2 wk

 B) 5 days C) 8 days

 D) 10 days

Answer

• B) 5 days

MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS

Which one of the following is a characteristic of a mild asthma

exacerbation?  (check one)

 A. Dyspnea at rest.  B. Perspiration. 

 C. Peak expiratory flow of less than 40 percent of personal best. 

 D. Dyspnea only with activity. 

Answer

•  D. Dyspnea only with activity.

Which one of the following home-based treatments has been shown to produce modest benefits in

children with frequent acute asthma exacerbations?  (check one)

 A. A short course of oral prednisolone at the onset of worsening symptoms. 

 B. Increased dosage of a long-acting beta2 agonist.  C. Increased dosage of inhaled corticosteroids. 

 D. Continuous beta2 agonist treatment. 

Answer

• A. A short course of oral prednisolone at the onset of worsening symptoms.

Which of the following are considered risk factors for repeat emergency department visits for acute asthma

symptoms in children?  (check all that apply)

 A. Age older than 10 years.  B. Age younger than two years. 

 C. Public health insurance.  D. Hispanic ethnicity. 

Answer

•  B. Age younger than two years.  C. Public health insurance.  D. Hispanic ethnicity. 

Clinical giudlines• Inhaled short-acting beta2 agonists are the cornerstones of treatment for acute asthma.

• C

• An inhaler with a spacer is equivalent to nebulized short-acting beta2 agonist therapy in children and adults.

• A

• Continuous beta2 agonist administration reduces hospital admissions in patients with severe acute asthma.

• A• Inhaled anticholinergic medication improves lung function and decreases hospitalization in school-age children with

severe asthma exacerbations.• A

• When multiple doses are used in combination with short-acting beta2agonists

• Intravenous magnesium sulfate increases lung function and decreases hospitalizations in children with an acute asthma exacerbation.

• A• The administration of systemic corticosteroids within one hour of emergency department presentation decreases the

need for hospitalization.• A• Largest effect noted in patients with severe asthma• Oral and parenteral corticosteroids are equally effective in preventing hospital admission in children.• B

Diagnosis• Asthma exacerbations can be classified as mild, moderate, severe, or life

threatening

• Criteria for severity are based on symptoms and physical examination parameters, as well as lung function and oxygen saturation.

• Although no single parameter has been identified to assess exacerbation severity, lung function is a useful method of assessment, with a PEF of 40 percent or less of predicted function indicating a severe attack in patients five years or older.

• The most useful signs for determining the severity of an asthma exacerbation in children younger than five years, or any child unable to perform a PEF, include the use of accessory muscles of respiration, chest wall retractions, tachypnea greater than 60 breaths per minute, cyanosis, and the presence of inspiratory and expiratory wheezing.

• For all patients, pulse oximetry on room air is a useful initial assessment. An oxygen saturation of less than 92 to 94 percent one hour after beginning standard treatment is a strong predictor of the need for hospitalization

Management• HOME TREATMENT• Early treatment is the most effective strategy for managing asthma exacerbations. • It is essential to teach patients how to monitor signs and symptoms, and take

appropriate action. • Patients who have a written asthma action plan and appropriate medication can

often manage mild exacerbations at home. • Key components of an asthma action plan that have reduced emergency

department visits and hospitalization include standard written instructions; criteria based on symptoms or PEF (compared with personal best) to trigger action; two to three action points; and individualized, written instructions on the use of inhaled or oral corticosteroids. 

• Patients at risk of asthma-related death may need more intensive treatment in a monitored setting at the first sign of an exacerbation. These patients should have an asthma action plan that emphasizes early communication with their physician.

Magnessium• The addition of intravenous magnesium sulfate to standard therapy

has been studied in adults and children with divergent results. In adults with severe exacerbations of asthma (PEF of 25 to 30 percent or less of predicted function), intravenous magnesium sulfate therapy resulted in slightly better lung function but no change in rates of hospitalization.

• In children one to 18 years of age, intravenous magnesium sulfate (25 to 100 mg per kg) has been demonstrated to significantly increase lung function and to decrease hospitalizations.

• Nebulized magnesium sulfate has a weak effect on respiratory function and hospital admission rates in adults, and no effect on either outcome in children

Steroids• The administration of systemic corticosteroids (500 mg hydrocortisone sodium

succinate injection [Solu-Cortef] or 125 mg methylprednisolone sodium succinate injection [Solu-Medrol] in adults, or 1 to 2 mg per kg of prednisone or prednisolone in children one to 18 years of age) within one hour of emergency department presentation decreases the need for hospitalization.In a Cochrane review, the most pronounced effect occurred in patients with severe exacerbations.

• Oral and parenteral corticosteroids are equally effective in preventing hospital admission in children, but only parenteral corticosteroids have been studied in adults.

• There is insufficient evidence to recommend the use of inhaled corticosteroids in place of or in conjunction with systemic corticosteroids at the time of discharge from the emergency department. Inhaled corticosteroids do not prevent relapse of symptoms requiring admission or improve quality of life or symptom scores

POSTDISCHARGE CARE • Patients sent home from the emergency department with systemic

corticosteroids (a five- to 10-day nontapering course of 50- to 100-mg prednisone per day in adults) have decreased relapse of asthma symptoms, future hospitalizations, and use of short-acting beta2 agonists. Although seven to 10 days is the usual treatment duration for oral corticosteroids, three days of therapy (1 mg per kg of prednisone) has been shown to be as effective as five days for the complete resolution of symptoms within one week in children two to 15 years of age.

• There are insufficient data to recommend the initiation of montelukast in place of oral corticosteroids or the use of inhaled corticosteroids in combination with oral corticosteroids at the time of discharge to prevent a relapse of asthma symptoms.

DIAGNOSIS AND TREATMENT OF LICHEN PLANUS

Which one of the following statements about the treatment of oral lichen planus is correct?   (check

one)

 A. Complete resolution is difficult to achieve.  B. Systemic corticosteroids are first-line treatments.  C. Carbon-dioxide laser evaporation is ineffective.  D. Adrenal suppression is a common complication

of topical steroid use. 

Answer

• A. Complete resolution is difficult to achieve.

A patient presents with hypertrophic pruritic lichen planus on the ankles.

Which one of the following is the most appropriate treatment?  (check one)

 A. Intralesional triamcinolone (Kenalog). 

 B. Acitretin (Soriatane).  C. Topical lidocaine (Xylocaine).  D. Topical pimecrolimus (Elidel). 

Answer

•  A. Intralesional triamcinolone (Kenalog). 

Which of the following are appropriate topical treatments for genital lichen planus?   (check all

that apply)

 A. Triamcinolone (Triderm).  B. Tacrolimus (Protopic).  C. Clobetasol (Temovate). 

 D. Aloe vera gel. 

Lichen planus• Lichen planus is a chronic, inflammatory, autoimmune disease that affects the skin, oral mucosa, genital

mucosa, scalp, and nails. • Lichen planus lesions are described using the six P's (planar [flat-topped], purple, polygonal, pruritic,

papules, plaques). • Onset is usually acute, affecting the flexor surfaces of the wrists, forearms, and legs. • The lesions are often covered by lacy, reticular, white lines known as Wickham striae. • Classic cases of lichen planus may be diagnosed clinically, but a 4-mm punch biopsy is often helpful and is

required for more atypical cases. • High-potency topical corticosteroids are first-line therapy for all forms of lichen planus, including cutaneous,

genital, and mucosal erosive lesions. • In addition to clobetasol, topical tacrolimus appears to be an effective treatment for vulvovaginal lichen

planus. • Topical corticosteroids are also first-line therapy for mucosal erosive lichen planus. • Systemic corticosteroids should be considered for severe, widespread lichen planus involving oral, cutaneous,

or genital sites. • Referral to a dermatologist for systemic therapy with acitretin (an expensive and toxic oral retinoid) or an

oral immunosuppressant should be considered for patients with severe lichen planus that does not respond to topical treatment.

• Lichen planus may resolve spontaneously within one to two years, although recurrences are common. • However, lichen planus on mucous membranes may be more persistent and resistant to treatment.

Clinical Recomendations• High-potency topical corticosteroids should be first-line treatments for all

forms of lichen planus.• B• Topical calcineurin inhibitors, such as tacrolimus (Protopic) and

pimecrolimus (Elidel), should be used as second-line therapies to treat genital and oral lichen planus.

• B• Intralesional triamcinolone acetonide (Kenalog), 5 to 10 mg per mL

injection, should be used to treat hypertrophic lichen planus.• B• Three to six weeks of oral prednisone therapy should be used to treat severe,

widespread lichen planus (tapered course, 30 to 60 mg per day starting dose).• B

Answer

•  A. Triamcinolone (Triderm).  B. Tacrolimus (Protopic).  C. Clobetasol (Temovate).  D. Aloe vera gel. 

Diagnosis• Lichen planus can be diagnosed clinically in classic cases, although

biopsy is often helpful to confirm the diagnosis and is required for more atypical presentations.

• A 4-mm punch biopsy should be adequate on the skin or in the mouth.

• The histology shows a characteristic “saw-tooth” pattern of epidermal hyperplasia; hyperparakeratosis with thickening of the granular cell layer; and vacuolar alteration of the basal layer of the epidermis, with an intense infiltration (mainly T cells) at the dermal-epidermal junction.

• A 4-mm punch biopsy of perilesional skin for direct immunofluorescence may be added to the workup when bullous lesions, pemphigus, or bullous pemphigoid is present. Tables 2 and 3 present the differential diagnosis of cutaneous and oral lichen planus.

Treatment• CUTANEOUS LICHEN PLANUS

• Cutaneous lichen planus may resolve spontaneously within one to two years, although lichen planus affecting mucous membranes may be more persistent and resistant to treatment.

• Recurrences are common, even with treatment.  

• High-potency topical corticosteroids are first-line therapy for cutaneous lichen planus.

•  Oral antihistamines (e.g., hydroxyzine [Vistaril]) may be used to control pruritus.

• Hypertrophic lesions are treated with intralesional triamcinolone acetonide (Kenalog), 5 to 10 mg per mL injection (0.5 to 1 mL per 2-cm lesion)

OUTPATIENT APPROACH TO PALPITATIONS

Which one of the following is the most common cardiac structural

cause of palpitations?   (check one)

 A. Bicuspid aortic valve.  B. Pulmonary stenosis.  C. Atrial septal defect. 

 D. Mitral valve prolapse. 

Answer

•  D. Mitral valve prolapse. 

Which one of the following statements about supraventricular tachycardia is correct?   (check one)

 A. Wide complex supraventricular tachycardia is easily distinguished from ventricular tachycardia.  B. Vagal maneuvers should be used for treatment

only as a last resort.  C. Intravenous adenosine (Adenocard) is an

effective option for drug therapy.  D. Verapamil should never be used in patients with

refractory episodes. 

Answer

•  C. Intravenous adenosine (Adenocard) is an effective option for drug therapy. 

Which of the following are independent predictors of an arrhythmic cause of palpitations?   (check all that apply)

 A. Visible neck pulsations.  B. Palpitations at work. 

 C. Palpitations affecting sleep.  D. Duration of palpitation less than five

minutes. 

Answer

•  A. Visible neck pulsations.  B. Palpitations at work.  C. Palpitations affecting sleep

Palpitations• Palpitations are a common problem seen in family medicine; most are of cardiac origin, although an

underlying psychiatric disorder, such as anxiety, is also common. • Even if a psychiatric comorbidity does exist, it should not be assumed that palpitations are of a

noncardiac etiology. • Discerning cardiac from noncardiac causes is important given the potential risk of sudden death in

those with an underlying cardiac etiology. • History and physical examination followed by targeted diagnostic testing are necessary to distinguish a

cardiac cause from other causes of palpitations. • Standard 12-lead electrocardiography is an essential initial diagnostic test. • Cardiac imaging is recommended if history, physical examination, or electrocardiography suggests

structural heart disease. • An intermittent event (loop) monitor is preferred for documenting cardiac arrhythmias, particularly

when they occur infrequently. • Ventricular and atrial premature contractions are common cardiac causes of palpitations; prognostic

significance is dictated by the extent of underlying structural heart disease. • Atrial fibrillation is the most common arrhythmia resulting in hospitalization; such patients are at

increased risk of stroke.• Patients with supraventricular tachycardia, long QT syndrome, ventricular tachycardia, or

palpitations associated with syncope should be referred to a cardiologist.

Clinical Recommendations• All patients presenting with palpitations should be evaluated for a

cardiac cause.

• C

• A positive history or abnormal results on physical examination or electrocardiography should prompt evaluation for structural heart disease.

• C

• Supraventricular tachycardia with aberrant conduction may be difficult to distinguish from ventricular tachycardia. In the setting of hemodynamic instability or history of heart disease, ventricular tachycardia should be considered.

• C

Selected Other Causes of PalpitationsAlcoholAnemiaAnxiety

Beta-blocker withdrawalCaffeineCocaineExercise

FeverFood poisoning Hypoglycemia

HypovolemiaMastocytosis

Medications (see Table 5)Nicotine

Paget diseasePheochromocytoma

PregnancyStress

Thyroid disorders

History and Physical Examination• Discerning cardiac from noncardiac causes is important, given the potential risk of sudden death

in those with an underlying cardiac etiology. • All patients presenting with palpitations should be evaluated for a cardiac cause.•  A history of panic attacks or anxiety disorder points to a psychiatric cause,4 whereas a family

history of hyperthyroidism suggests a thyroid disorder.•  Important cardiac causes, such as long QT syndrome, have a heritable component,

underscoring the value of a meticulous family history.• Physicians should ask about the context of palpitations, noting that cardiac causes may occur

either at rest (e.g., vagally mediated premature ventricular beats) or with exertion (e.g., dehydration exacerbating mitral valve prolapse).

• Because most patients presenting with palpitations are asymptomatic at the time of the visit, the examination is focused primarily on uncovering abnormalities that may indicate structural heart disease or arrhythmia.A positive history or abnormal results on physical examination or electrocardiography (ECG) should prompt evaluation for structural heart disease.

• Physicians should assess for pulse irregularity, murmurs, point of apical impulse, or presence of a pulse discrepancy as seen in coarctation of the aorta (a pulse rate at the wrist that is lower than that at the apex of the heart)

LONG QT SYNDROME• Long QT syndrome is characterized by a prolonged QT interval on

ECG: more than 460 msec for women and more than 440 msec for men.• In addition to palpitations, patients with long QT syndrome often

experience syncope and have an increased risk of cardiac arrest.•  Patients with long QT syndrome should be referred to a cardiologist.• Medications  can cause an acquired long QT syndrome, which is more

common than familial QT prolongation.•  Physical and emotional stress are common triggers, with resultant life-

threatening torsades de pointes.• Beta blockade may be appropriate in some forms.• Implantation of a cardiac defibrillator is recommended in those at risk

of sudden cardiac death

• Selected Medications and Drug Classes Associated with Long QT SyndromeAmphetamines• Antiarrhythmics (e.g., amiodarone [Cordarone], disopyramide [Norpace], procainamide,

quinidine, sotalol [Betapace])• Anticholinergics• Antihistamines (e.g., diphenhydramine [Benadryl], hydroxyzine [Vistaril])• Decongestants• Diuretics• Fluoroquinolone antibiotics• Macrolide antibiotics• Phenothiazines• Protease inhibitors• Selective serotonin reuptake inhibitors• Sympathomimetics• Tricyclic antidepressants• Vasodilators

WOLFF-PARKINSON-WHITE SYNDROME

• Wolff-Parkinson-White (WPW) syndrome is a preexcitation syndrome characterized by electrical impulses traveling along an accessory pathway, thereby triggering ventricular excitation before the normal impulse arrives.

• The most common disturbance in those with WPW syndrome is atrioventricular nodal reentrant tachycardia, accounting for 95 percent of such cases.6

• These patients often present with a heart rate of more than 250 beats per minute, which can result in life-threatening hypotension due to decreased ventricular filling time.

•  Although medical management is sometimes used, catheter ablation is now the standard of care in patients with WPW syndrome.

•  Patients with WPW syndrome who present with rapid AF and wide complex tachycardia warrant judicious treatment selection.

• In such patients, atrioventricular nodal blocking agents may cause degeneration of the rhythm and further hemodynamic instability, which may be recognized by careful interpretation of the ECG.

Office Management of Early Pregnancy Loss• The management of early pregnancy loss used to be based largely in the hospital setting, but it has

shifted to the outpatient setting, allowing women to remain under the care of their family physician throughout the miscarriage process.

• Up to 15 percent of recognized pregnancies end in miscarriage, and as many as 80 percent of miscarriages occur in the first trimester, with chromosomal abnormalities as the leading cause.

• In general, no interventions have been proven to prevent miscarriage; occasionally women can modify their risk factors or receive treatment for relevant medical conditions.

• Unless products of conception are seen, the diagnosis of miscarriage is made with ultrasonography and, when ultrasonography is not available or is nondiagnostic, with measurement of beta subunit of human chorionic gonadotropin levels.

• Management options for early pregnancy loss include expectant management, medical management with misoprostol, and uterine aspiration. Expectant management is highly effective for the treatment of incomplete abortion, whereas misoprostol and uterine aspiration are more effective for the management of anembryonic gestation and embryonic demise. Misoprostol in a dose of 800 mcg administered vaginally is effective and well-tolerated.

• Compared with dilation and curettage in the operating room, uterine aspiration is the preferred procedure for early pregnancy loss; aspiration is equally safe, quicker to perform, more cost-effective, and amenable to use in the primary care setting. All management options are equally safe; thus, patient preference should guide treatment choice.

Clinical Recomendations• Transvaginal ultrasonography is a reliable way to differentiate between viable and nonviable pregnancies and should be

performed when early pregnancy loss is suspected.

• C

• Because better mental health outcomes result when patient preferences for treatment are respected and because all treatment options are safe, expectant management, medical management with misoprostol (Cytotec), and uterine aspiration should be offered to women for the treatment of early pregnancy loss.

• A

• Given that expectant management is up to 90 percent effective, it is a reasonable first-line option for incomplete abortion.

• B

• Compared with expectant management, medical management with misoprostol hastens completed abortion, especially in cases of anembryonic gestation and embryonic demise.

• A

• Compared with dilation and curettage in the operating room, uterine aspiration is the preferred procedure for early pregnancy loss because aspiration is equally safe, quicker to perform, more cost-effective, and amenable to use in the primary care setting.

• A

• There is insufficient evidence to recommend routine antibiotic prophylaxis following uterine aspiration.

• C

• Women experiencing early pregnancy loss should be reassured that subsequent fertility is not adversely affected by any of the three treatment options (expectant care, medical management with misoprostol, or uterine aspiration).

• B

EXPECTANT MANAGEMENT

• Many women will first elect to take a “wait and see” approach in hopes that they will complete their miscarriage without intervention.

• For incomplete abortion, the success rate of this approach is up to 90 percent, although it may take weeks for complete passage of the tissue.

• A follow-up appointment to assess completion of the miscarriage and to process the experience is important.

• A repeat ultrasonography showing the absence of a previously documented pregnancy or an 80 percent drop in the β-hCG level one week following the passage of tissue confirms completion.

• If using β-hCG levels, there is no need to follow them to zero unless ectopic pregnancy has not been reliably excluded.

• However, for cases in which an intrauterine pregnancy has not been documented, it is prudent to follow β-hCG levels to resolution because ectopic pregnancies can present with declining β-hCG levels.

• In the absence of hemorrhage or infection, there is no limit to how long it is safe to wait for the miscarriage to complete naturally.

• If a patient decides that she wants the process to be over, however, she can switch from expectant care to medical management or an aspiration procedure at any point.

OFFICE MANAGEMENT OF EARLY PREGNANCY LOSS

A patient with a newly diagnosed pregnancy and a previous miscarriage at five weeks' gestation has

been diagnosed with a threatened abortion. Which one of the following measures may effectively

prevent miscarriage?   (check one)

 A. Bed rest.  B. Vitamin supplementation. 

 C. Progestogen use.  D. Uterine muscle relaxants. 

 E. None of the above. 

Answer

•  E. None of the above. 

A pregnant patient with vaginal spotting has no visible pregnancy on transvaginal ultrasonography

and an initial beta subunit of human chorionic gonadotropin (β-hCG) level of 600 mIU per mL. She has a level of 1,100 mIU per mL 48 hours later. Her third β-hCG level, measured another 48 hours later, is 2,500 mIU per mL. This is suggestive of which

one of the following?   (check one)

 A. An ectopic pregnancy.  B. Early pregnancy failure. 

 C. A viable pregnancy.  D. Completed abortion. 

Answer

•  C. A viable pregnancy. 

A patient in stable condition chooses expectant management after confirmation of an intrauterine embryonic demise. In regard to this patient, which of the following statements are

correct?   (check one)

 A. Her β-hCG levels should be followed to zero.  B. She can safely switch to medical management at any

time.  C. She should be given a course of antibiotics. 

 D. She should have an aspiration procedure if she has not passed tissue within two weeks of diagnosis. 

Answer

•  B. She can safely switch to medical management at any time. 

COCHRANE FOR CLINICIANS: PUTTING EVIDENCE INTO PRACTICE

PROBIOTICS FOR PERSISTENT DIARRHEA IN CHILDREN

Probiotics have been shown to be beneficial for treating which of the following conditions?   (check

all that apply)

 A. Irritable bowel syndrome.  B. Acute pancreatitis. 

 C. Acute diarrhea.  D. Persistent diarrhea. 

Answer

•  A. Irritable bowel syndrome.   C. Acute diarrhea.  D. Persistent diarrhea. 

Asthma• Asthma exacerbations can be classified as mild, moderate, severe, or life threatening.

• Criteria for exacerbation severity are based on symptoms and physical examination parameters, as well as lung function and oxygen saturation.

• In patients with a peak expiratory flow of 50 to 79 percent of their personal best, up to two treatments of two to six inhalations of short-acting beta2 agonists 20 minutes apart followed by a reassessment of peak expiratory flow and symptoms may be safely employed at home.

• Administration using a hand-held metered-dose inhaler with a spacer device is at least equivalent to nebulized beta2 agonist therapy in children and adults.

• In the ambulatory and emergency department settings, the goals of treatment are correction of severe hypoxemia, rapid reversal of airflow obstruction, and reduction of the risk of relapse.

• Multiple doses of inhaled anticholinergic medication combined with beta2 agonists improve lung function and decrease hospitalization in school-age children with severe asthma exacerbations.

• Intravenous magnesium sulfate has been shown to significantly increase lung function and decrease the necessity of hospitalization in children.

• The administration of systemic corticosteroids within one hour of emergency department presentation decreases the need for hospitalization, with the most pronounced effect in patients with severe exacerbations.

• Airway inflammation can persist for days to weeks after an acute attack; therefore, more intensive treatment should be continued after discharge until symptoms and peak expiratory flow return to baseline.