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Primary Care Update

Primary Care Update. Erik A. Wallace, MD, FACP Associate Professor ACP Oklahoma Chapter Meeting October 8, 2010. Thank You. Scott C. Litin, MD, MACP John B. Bundrick, MD, FACP Lynn T. Shuster, MD, FACP. Case 1.

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Primary Care Update

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  1. Primary Care Update Erik A. Wallace, MD, FACP Associate Professor ACP Oklahoma Chapter Meeting October 8, 2010

  2. Thank You • Scott C. Litin, MD, MACP • John B. Bundrick, MD, FACP • Lynn T. Shuster, MD, FACP

  3. Case 1 • 69 yo man w/hyperlipidemia and HTN has had two episodes of classic podagra per year for the past three years. • He developed a rash and nausea after taking allopurinol in the past. • No history of nephrolithiasis and does not use alcohol. He has a mild peripheral neuropathy (idiopathic) and diarrhea-predominant IBS. • He is taking gemfibrozil, atenolol, and lisinopril.

  4. Case 1 • On exam, his BMI is 26 kg/m2, BP 130/70, pulse 60/regular. He has a small tophus on the DIP of his right index finger, and the exam is otherwise unremarkable. • Labs: CBC, AST, ALT are normal. • Creatinine is 1.0 mg/dl • Serum uric acid is 7.2 mg/dl • Total cholesterol is 198 mg/dl; Triglycerides 149 mg/dl; LDL 129 mg/dl; and HDL 39 mg/dl.

  5. 0 of 30 Case 1 Question What would be the best step in reducing his risk of recurrent gout at this point? • Switch the gemfibrozil to fenofibrate • Switch the gemfibrozil to niacin • Add colchicine 0.6mg per day • Switch lisinopril to irbesartan • Switch lisinopril to candesartan

  6. Case 1 Discussion • Hyperuricemia and gout often occur in the context of hypertension and hyperlipidemia. • Patients may be intolerant of allopurinol, have hyperuricemia that is suboptimally controlled on it, or simply may not wish to add an additional medication to their regimen. • There are a couple of medications used for hyperlipidemia and hypertension that have the additional effect of lowering levels of serum uric acid (by enhancing uric acid excretion).

  7. Case 1 Discussion • Fenofibrate • Decreases serum uric acid by 20-30%, even in patients with tophaceous gout who are already taking allopurinol. • This effect is not seen with gemfibrozil • Niacin is contraindicated in patients with gout.

  8. Case 1 Discussion • Losartan • Decreases serum levels of uric acid by approximately 10-15%, even in patients who are already taking fenofibrate. • 100 mg daily not more effective than 50 mg • This effect is not seen with other angiotensin receptor blockers • In patients with HTN, overall benefits may be further multiplied by replacing a thiazide diuretic with losartan.

  9. Case 1 Discussion • Since losartan and fenofibrate lower serum urate by means of uricosuria, these agents should be avoided in patients with a history of uric acid nephrolithiasis.

  10. Case 1 Discussion • Colchicine • Not be a good long term option in this patient • May potentially worsen his neuropathy or his bowel symptoms • Would not address the underlying problem of hyperuricemia and urate deposition

  11. Case 1 Clinical Pearl • Fenofibrate and losartan have uric acid lowering effects and may be agents of choice in patients with primary indications for either drug with coexisting hyperuricemia. • References: • 1.Feher MD, Hepburn AL, Hogarth MB, et al.Fenofibrate enhances urate reduction in mentreated with allopurinol for hyperuricaemia and gout.Rheumatology 2003;42:321-325. • 2.Wurzner G, Gerster JC, Chiolero A, et al.Comparative effects of losartan and irbesartanon serum uric acid in hypertensive patients with hyperuricaemia and gout. J Hypertens 2001; 19:1855-1860.

  12. Case 2 • A 32 year old woman, previously healthy, presents with 2 days of right flank pain radiating to the right groin • Denies any dysuria, urgency, frequency, or fever and has no prior history of nephrolithiasis • Pain is fairly well controlled on naproxen 220 mg BID and she is on no other medications. • Her UA shows 4-10 RBC’s. Gram stain is negative. Serum Cr is 1.0 mg/dl. Her CT, kidney stone protocol, shows a 5mm calculus at the right ureterovesical junction.

  13. 0 of 30 Case 2 Question Beyond the usual advice to increase fluids and strain the urine, what would be the most appropriate next step? • Urology consultation • Verapamil • Oxybutynin • Tamsulosin • Bethanechol

  14. Case 2 Discussion • 5 mm stone in the distal ureter • 50-60% chance of spontaneous passage • In the absence of infection, renal failure, or unmanageable pain, may be managed conservatively for up to four weeks. • The average time to passage in some studies is as long as 22 days, and thus it is reasonable to use “medical expulsive therapy” (MET) to expedite resolution.

  15. Case 2 Discussion • Alpha-antagonists and calcium channel blockers • Inhibit contraction of the smooth muscle responsible for ureteral spasms (while still allowing antegrade stone propagation). • Tamsulosin, 0.4 mg per day given for up to 1 month. • Ureteral stones 5-7 mm in diameter, stones passed an average of 2 to 6 days earlier • Mean time to stone expulsion was less than 14 days • Nifedipine: slightly less effective than tamsulosin.

  16. Case 2 Clinical Pearl • Both tamsulosin and nifedipine have been shown to expedite the expulsion of moderate-sized distal ureteral calculi. • References: • 1.Singh A, Alter HJ, Littlepage A. A systematic review of medical therapy to facilitate passageof ureteral calculi. Ann Emerg Med. Nov 2007;50(5):552-563. • 2.Lojanapiwat B, Kochakarn W, Suparatchatpan N, Lertwuttichaikul K. Effectiveness oflow-dose and standard-dose tamsulosin in the treatment of distal ureteric stones: a randomized controlled study. J Int Med Res. May-Jun 2008;36(3):529-536.

  17. Case 3 • A 26 year old woman presents with 18 months of RUQ abdominal pain which began after an episode of self limited viral gastroenteritis. • She describes it as a “sharp” and “burning” discomfort that is well localized and continuous. It may be slightly worse after eating and definitely seems to worsen after a bowel movement. Her bowels are moving normally, and there is no weight loss or fever. ROS is otherwise unremarkable. • She was previously healthy apart from mild depression which is being effectively treated with fluoxetine. She is on no other medications. No smoking or ethanol.

  18. Case 3 • Exam: BMI = 30 kg/m2 Moderate focal tenderness RUQ • Labs: CBC and chemistries normal except for ALT 50 (with AST of 30) • RUQ ultrasound • Sludge in the gallbladder with a normal liver • EGD normal

  19. 0 of 30 Case 3 Question The next step most likely to yield the diagnosis would be: • HIDA Scan • Empiric trial of omeprazole • Checking for Murphy’s sign • Performing the Carnett’s maneuver • Mesenteric arterial doppler study

  20. Case 3 Discussion • Chronic abdominal wall pain (CAWP) • British surgeon Dr. J.B. Carnett in 1926 • Obesity and depression are common co-morbidities, as are fibromyalgia and other painful conditions.

  21. Case 3 Discussion • Carnett’s Maneuver • Tender spot is located and then the patient is asked to raise either their legs or torso (thus tensing the abdominal muscles). • If the pain does not decrease (and especially if it increases) during the maneuver, then it is very unlikely to be from a visceral source and may reliably be localized to the abdominal wall muscles. • False positive Carnett’s maneuvers occur infrequently (<5%) • After eating (abdominal distention) or more commonly after bowel movement (from straining of the abdominal muscles).

  22. Case 3 Discussion • Carnett’s maneuver is not only useful in diagnosis, but is also helpful in education and reassuring the patient as to the true source of their pain. • Local heat or ice treatments, sometimes accompanied by gentle stretching of the abdominal muscles, have been tried with variable success. • With a conservative approach, about 50% of patients will improve over several months of follow-up. • Trigger point injections provide relief in about 2/3 of patients. • In all cases, the diagnosis helps to provide reassurance, while avoiding unnecessary expense, testing, and confusion.

  23. Case 3 Discussion • In this case, the pain is too constant and chronic to represent biliary colic • Elevated ALT is compatible with fatty liver. • The features are not compatible with GERD and EGD did not show any gastritis or ulceration (thus a trial of PPI is unlikely to be of benefit). • She doesn’t have atrial fibrillation, is far too young to have symptomatic atherosclerosis (the most common conditions associated with mesenteric ischemia), and the pattern is not suggestive of that entity.

  24. Case 3 Clinical Pearl • In patients with chronic abdominal wall pain (CAWP), the Carnett’s maneuver can be very useful in both diagnosing and reassuring the patient. • References: • 1.Srinivasan R, Greenbaum DS. Chronic Abdominal Wall Pain: A Frequently OverlookedProblem. Am J Gastroenterol. 2002;97:824-30. • 2.Costanza CD, Longstreth GF, Liu AL. Chronic Abdominal Wall Pain: Clinical Features,Health Care Costs, and Long-term Outcome. Clin Gastroenterol and Hepatology. 2004;2:395- 399.

  25. Case 4 • A 79 year old man was diagnosed with prostate cancer 3 years ago after an area of induration was found on rectal examination. Biopsy revealed Gleason 3+4 adenocarcinoma at that time. • He was treated with a course of external beam radiation therapy which was well tolerated • PSA dropped from a baseline level of 2.8 down to a nadir of 0.3 ng/ml. He continued to feel well but had biochemical recurrence of his cancer, with his PSA nine months ago rising to 2.3 ng/ml • This prompted the initiation of androgen deprivation therapy at that time with leuprolide and bicalutamide.

  26. Case 4 • He has mild hot flashes but otherwise feels well. He specifically denies any pain, dyspnea, neurologic symptoms, abdominal discomfort, melena, or hematochezia. His examination is unremarkable. • Screening colonoscopy 2 years ago was normal. • Meds: Omeprazole, lisinopril, hydrochlorothiazide, leuprolide, bicalutamide, alendronate, Vitamin D, calcium. • Labs: Hgb 12.3 g/dl (year ago was 14.2 g/dl). MCV 90 fl. WBC and platelets normal. Serum creatinine 1.2 mg/dl. PSA is <0.10 ng/ml.

  27. 0 of 30 Case 4 Question What would be the most appropriate next step to evaluate his anemia? • Stop omeprazole • Bone scan • Repeat colonoscopy • Serum ferritin • Recheck Hgb in 3-6 months

  28. Case 4 Discussion • Normal range of hemoglobin in men is about 2 g/dl higher than women • Due almost exclusively to the influence of testosterone. • Biochemically castrated men would be expected to have serum hemoglobin within the normal female range. • In men with localized prostate cancer who are placed on androgen deprivation therapy, the mean drop in Hgb over six months was 1.5 g/dl to 2.6 g/dl. The MCV remains normocytic. • In those who discontinue androgen deprivation therapy, the recovery is slow and parallels the recovery of testosterone. • Only about 14% of patients develop Hgb of 10 or lower with symptoms referable to anemia.

  29. Case 4 Discussion • He has no data to suggest iron deficiency and has a good explanation for his drop in Hgb • No need for ferritin and certainly not for repeat colonoscopy • While omeprazole may interfere with iron absorption in those who are on replacement, it should not produce a de novo normocytic anemia. • His prostate cancer is biochemically in remission and he has no bone symptoms.

  30. Case 4 Clinical Pearl • Androgen deprivation therapy produces a predictable drop in hemoglobin, which in the absence of bleeding or other causes of anemia does not require additional testing. • References: • 1.Strum SB, McDermed JE, Scholz MC, Johnson H, Tisman G. Anaemia associated withandrogen deprivation in patients with prostate cancer receiving combined hormone blockade.Br J Urol. Jun 1997;79(6):933-941. • 2.Bogdanos J, Karamanolakis D, Milathianakis C, Repousis P, Tsintavis A, Koutsilieris M.Combined androgen blockade-induced anemia in prostate cancer patients without bone involvement. Anticancer Res. Mar-Apr 2003;23(2C):1757-1762.

  31. Case 5 • A 78 year old man with DM2 has been well controlled on metformin for the past five years. • Reports mild paresthesias and decreased sensation in his toes over the past year, but otherwise has had no complications of his disease. • Otherwise healthy apart from HTN and hyperlipidemia which are well controlled on lisinopril and simvastatin.

  32. Case 5 • Medications • Metformin 1 gram twice daily • Lisinopril 10 mg per day • Simvastatin 20 mg per day • ASA 81 mg per day • Examination • Appears healthy, BP 120/70, P 68/reg, Wt 75 kg • Mildly reduced vibratory sensation in the toes, exam otherwise normal.

  33. Case 5 • Labs: • CBC, AST, electrolytes all normal. • Creatinine 1.2 g/dl • Glucose 116 mg/dl • HgbA1c 6.3% • Microalbumin negative • LDL 74 mg/dl • HDL 46 mg/dl.

  34. 0 of 30 Case 5 Question Which of the following additional tests would be most useful to check at this visit? • Vitamin B 12 • 25-OH Vitamin D • Serum folate • Serum homocysteine • Serum ubiquinone (Coenzyme Q10)

  35. Case 5 Discussion • Metformin has been associated with Vitamin B12 deficiency • More likely to occur after more than three years use. • Dose-related phenomenon and more prevalent at doses of more than 1.5 grams per day • Average B12 levels are in the range of 150 pg/ml • The clinical severity is mild to moderate in most cases, with mild peripheral neuropathy and anemia (Hgb in the 11 range) being the most common findings in those who are symptomatic. • Homocysteine is often modestly elevated as well (but there would be no indication to check it in this particular case).

  36. Case 5 Discussion • The mechanism is thought to be malabsorption of food-cobalamin in the distal ileum • The ileum cell surface receptor depends on intraluminal calcium to function effectively, and metformin interferes with this interaction. • One report of patients on metformin indicated significant improvement in B12 absorption with increased intake of calcium. • It would be reasonable to check a B12 level periodically in patients who have been on metformin for several years.

  37. Case 5 Clinical Pearl • Significant deficiency of vitamin B12 may develop in patients who have been on metformin for several years. • References: • 1.Andres E, Federici L. Vitamin B12 deficiency in patients receiving metformin: clinical data.Arch Intern Med. Apr 9 2007;167(7):729; author reply 730-721. • 2.Ting RZ, Szeto CC, Chan MH, Ma KK, Chow KM. Risk factors of vitamin B(12)deficiency in patients receiving metformin. Arch Intern Med. Oct 9 2006;166(18):1975-1979.

  38. Case 6 • A 70 year old woman reports to your office for recheck of hypertension. • Her last Pap was two years ago and she reminds you she is due for a Pap smear this year. • She is monogamous with her husband of 50 years. • Prior Paps were negative and performed regularly, including three times over the past 10 years.

  39. Case 6 • Medications • Lisinopril 10 mg daily • Calcium with vitamin D twice daily • Multivitamin one daily • Fosamax 70 mg once weekly • Family history is notable for cervical cancer in her mother.

  40. 0 of 30 Case 6 Question Which of the following should you advise? • Pap test now, with reflex HPV test • Pap co-testing along with HPV test now • Pap test next year • Discontinuing Pap test screening • She may decide for herself how often to get Pap test screening

  41. Case 6 Discussion • Postmenopausal women with multiple prior consecutive negative Pap test results are low risk for cervical cancer. • Postmenopausal atrophy can predispose to false-positive results, potentially leading to unnecessary procedures, discomfort and expense. • The American Cancer Society thus recommends that screening may be discontinued at age 70 in low risk women, after three consecutive negative Pap tests in the prior decade. • The USPSTF recommends that routine screening should be discontinued after age 65 years.

  42. Case 6 Discussion • An older woman who is sexually active and has a new partner or multiple partners may be at lower risk for developing new onset CIN (cervical intraepithelial neoplasia) than a younger woman, due to a decreased rate of metaplasia and less accessible transformation zone, but is still at some risk for HPV infection and subsequent CIN. Thus risk factors should be assessed to determine if continuing or reinitiating screening might be appropriate after age 65. • A family history of cervical cancer does not affect screening frequency, since cervical cancer is associated with HPV infection and is not a heritable disorder.

  43. Case 6 Clinical Pearl • In the absence of identified increased risks for cervical cancer, Pap test screening may be discontinued at age 65 – 70 years. • Reference: • 1.ACOG Practice Bulletin: Cervical Cytology Screening. Obstetrics & Gynecology 2009;114:1409-1420.

  44. Case 7 • A healthy 20 yo woman presents to you as a new patient after her previous physician left town to start a concierge practice. • After reviewing her records, you note that 1 year ago, at age 19, she had a Pap smear which showed LGSIL. She was referred for colposcopy but she never followed up after losing her insurance. She has had 4 sexual partners in the past year and a history of gonorrhea treated with ceftriaxone. An HIV test was negative. • At a free clinic last month, she was seen for pelvic pain which resolved. She “thinks” she had a Pap smear done and “thinks” that it was “normal.” She does not know if HPV testing was done or any other details about her pelvic exam.

  45. 0 of 30 Case 7 Question What would you advise for follow-up in regards to cervical cancer screening for this 20 yo woman? • Perform HPV testing now. • Perform Pap smear and HPV in six months. • Perform Pap smear in one year. • Perform Pap smear in 2 years. • Refer to Gynecology for colposcopy

  46. Case 7 Discussion • 50% of women diagnosed with cervical cancer each year have never had a Pap smear • HPV infections are most common in teenagers and women in early 20’s • Most of these infections resolve spontaneously within 1-2 years, neoplastic transformation increases as the HPV infection persists • Abnormal Pap’s before 21 can lead to harm • 0.1% of cervical cancers occur in women <21 years • 1-2 cases/1 million women 15-19 years old

  47. Case 7 Discussion • Cervical cancer screening should start at age 21, regardless of previous sexual history, and repeated every 2 years until age 29 if normal. • Women age 30 or older with 3 consecutive negative Pap smears, no history of CIN2 or CIN3, HIV negative, no history of DES exposure, not immunocompromised can be rescreened every 3 years • Screening can stop if woman had TAH for non-cancerous lesions

  48. Case 7 Clinical Pearl • Pap smears should be performed in women starting at age 21, regardless of previous sexual history and should be repeated every 2 years until age 29. • Reference: • 1.ACOG Practice Bulletin: Cervical Cytology Screening. Obstetrics & Gynecology 2009;114:1409-1420.

  49. Case 8 • A 28 year old woman presents for refill of her birth control pill. She started the Pill one year ago to control heavy periods and for contraception. • Since starting the Pill she has experienced several episodes of a severe headache during the first two days of the Pill-free week monthy. • Headaches are preceded by visual symptoms consisting of a black spot surrounded by flashing lights, enlarging over about 30 minutes, fading away and then followed by a left sided headache lasting for 6-8 hours. She experiences nausea and light sensitivity with the headaches. • She generally takes an OTC headache analgesic and goes to bed. • She would like to continue the Pill, but wonders what she can do for the headaches. • Past medical history is negative for migraines.

  50. Case 8 • Medications • Norgestimate-ethinyl estradiol (Ortho Tri-Cyclen) – one daily for 21 days followed by 7 days of placebo or no Pill • Acetaminophen 250 mg – aspirin 250 mg – caffeine 65 mg (Excedrin migraine) – two at onset headache • Examination • Blood pressure 110/62 • Pulse 88 • Heart, lungs, abdomen, breast, pelvic and neurological examination negative

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