A new classification system that incorporates clinical and serologic data may be useful in the classification of idiopathic inflammatory myopathies, results of a recent analysis suggest.

By analyzing the patterns of relationships between 47 variables in this observational, retrospective cohort study, investigators identified 4 clusters of patients that corresponded to known idiopathic inflammatory myopathy subtypes.

Myositis-specific antibodies played a key role in predicting whether a patient belonged in a cluster, according to investigators, who noted that myositis-specific antibodies known to be associated with certain subgroups fell into the corresponding clusters they identified.

“This emphasizes that muscle biopsy may no longer be necessary for diagnosis of idiopathic inflammatory myopathies in patients with [myositis-specific antibodies] and corresponding phenotypes,” said the investigators, led by Kubéraka Mariampillai, PhD, of the Université Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France.

The study, described in JAMA Neurology, was based on data for 260 patients in the database of the French Myositis Network. The mean age of the patients was 62 years, and 63% were women.

Investigators conducted a multiple correspondence analysis based on 47 selected variables, including age, race, historical and recent diagnoses, dermatologic changes, creatine kinase levels, myositis-specific antibodies, and pathologic characteristics, among others.

Based on that analysis, they identified four subgroups corresponding to known entities: Dermatomyositis, inclusion body myositis, immune-mediated necrotizing myopathy, and antisynthetase syndrome.

Using decisional algorithm trees, investigators found that myositis-specific antibodies “played a key role in estimating connection to a cluster,” while by contrast, the pathologic data were “dispensable,” Dr. Mariampillai and her associates said.

The best tree omitted variables related to muscle biopsy and had a 78% correct estimation looking just at antisynthetase antibodies, dermatomyositis rash, and finger flexor scores of 3 or less, investigators said.

“The classification quality of the tree was appreciated on the basis of all classification criteria, with an overall sensitivity of 77.0% and a specificity of 92.0%,” the investigators said.

Patients with polymyositis were present in the study data, but fell mainly in the clusters corresponding to immune-mediated necrotizing myopathy and antisynthetase syndrome.

“This finding indicates that patients with polymyositis do not represent a subgroup of patients, and use of this term should probably be discontinued,” Dr. Mariampillai and coinvestigators said.

The study was supported by Association Française contre les Myopathies, and by CSL Behring, which partly funded the development of electronic case report forms. Dr. Mariampillai and colleagues reported no conflicts of interest related to this work.

SOURCE: Mariampillai K, et al. JAMA Neurol. 2018 Sep 10. doi: 10.1001/jamaneurol.2018.2598.

A new classification system that incorporates clinical and serologic data may be useful in the classification of idiopathic inflammatory myopathies, results of a recent analysis suggest.

By analyzing the patterns of relationships between 47 variables in this observational, retrospective cohort study, investigators identified 4 clusters of patients that corresponded to known idiopathic inflammatory myopathy subtypes.

Myositis-specific antibodies played a key role in predicting whether a patient belonged in a cluster, according to investigators, who noted that myositis-specific antibodies known to be associated with certain subgroups fell into the corresponding clusters they identified.

“This emphasizes that muscle biopsy may no longer be necessary for diagnosis of idiopathic inflammatory myopathies in patients with [myositis-specific antibodies] and corresponding phenotypes,” said the investigators, led by Kubéraka Mariampillai, PhD, of the Université Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France.

The study, described in JAMA Neurology, was based on data for 260 patients in the database of the French Myositis Network. The mean age of the patients was 62 years, and 63% were women.

Investigators conducted a multiple correspondence analysis based on 47 selected variables, including age, race, historical and recent diagnoses, dermatologic changes, creatine kinase levels, myositis-specific antibodies, and pathologic characteristics, among others.

Based on that analysis, they identified four subgroups corresponding to known entities: Dermatomyositis, inclusion body myositis, immune-mediated necrotizing myopathy, and antisynthetase syndrome.

Using decisional algorithm trees, investigators found that myositis-specific antibodies “played a key role in estimating connection to a cluster,” while by contrast, the pathologic data were “dispensable,” Dr. Mariampillai and her associates said.

The best tree omitted variables related to muscle biopsy and had a 78% correct estimation looking just at antisynthetase antibodies, dermatomyositis rash, and finger flexor scores of 3 or less, investigators said.

“The classification quality of the tree was appreciated on the basis of all classification criteria, with an overall sensitivity of 77.0% and a specificity of 92.0%,” the investigators said.

Patients with polymyositis were present in the study data, but fell mainly in the clusters corresponding to immune-mediated necrotizing myopathy and antisynthetase syndrome.

“This finding indicates that patients with polymyositis do not represent a subgroup of patients, and use of this term should probably be discontinued,” Dr. Mariampillai and coinvestigators said.

The study was supported by Association Française contre les Myopathies, and by CSL Behring, which partly funded the development of electronic case report forms. Dr. Mariampillai and colleagues reported no conflicts of interest related to this work.

SOURCE: Mariampillai K, et al. JAMA Neurol. 2018 Sep 10. doi: 10.1001/jamaneurol.2018.2598.

A new classification system that incorporates clinical and serologic data may be useful in the classification of idiopathic inflammatory myopathies, results of a recent analysis suggest.

By analyzing the patterns of relationships between 47 variables in this observational, retrospective cohort study, investigators identified 4 clusters of patients that corresponded to known idiopathic inflammatory myopathy subtypes.

Myositis-specific antibodies played a key role in predicting whether a patient belonged in a cluster, according to investigators, who noted that myositis-specific antibodies known to be associated with certain subgroups fell into the corresponding clusters they identified.

“This emphasizes that muscle biopsy may no longer be necessary for diagnosis of idiopathic inflammatory myopathies in patients with [myositis-specific antibodies] and corresponding phenotypes,” said the investigators, led by Kubéraka Mariampillai, PhD, of the Université Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France.

The study, described in JAMA Neurology, was based on data for 260 patients in the database of the French Myositis Network. The mean age of the patients was 62 years, and 63% were women.

Investigators conducted a multiple correspondence analysis based on 47 selected variables, including age, race, historical and recent diagnoses, dermatologic changes, creatine kinase levels, myositis-specific antibodies, and pathologic characteristics, among others.

Based on that analysis, they identified four subgroups corresponding to known entities: Dermatomyositis, inclusion body myositis, immune-mediated necrotizing myopathy, and antisynthetase syndrome.

Using decisional algorithm trees, investigators found that myositis-specific antibodies “played a key role in estimating connection to a cluster,” while by contrast, the pathologic data were “dispensable,” Dr. Mariampillai and her associates said.

The best tree omitted variables related to muscle biopsy and had a 78% correct estimation looking just at antisynthetase antibodies, dermatomyositis rash, and finger flexor scores of 3 or less, investigators said.

“The classification quality of the tree was appreciated on the basis of all classification criteria, with an overall sensitivity of 77.0% and a specificity of 92.0%,” the investigators said.

Patients with polymyositis were present in the study data, but fell mainly in the clusters corresponding to immune-mediated necrotizing myopathy and antisynthetase syndrome.

“This finding indicates that patients with polymyositis do not represent a subgroup of patients, and use of this term should probably be discontinued,” Dr. Mariampillai and coinvestigators said.

The study was supported by Association Française contre les Myopathies, and by CSL Behring, which partly funded the development of electronic case report forms. Dr. Mariampillai and colleagues reported no conflicts of interest related to this work.

SOURCE: Mariampillai K, et al. JAMA Neurol. 2018 Sep 10. doi: 10.1001/jamaneurol.2018.2598.

Youths with opioid use disorder (OUD) are more likely to remain in care if they receive medications to treat the condition, but very few are receiving them, results of a retrospective cohort study suggest.

Hailshadow/iStock/Getty Images

Prescribing buprenorphine, naltrexone, or methadone soon after an OUD diagnosis in this study was associated with increased retention in care for adolescents and young adults.

However, medications were provided to just 1 in 4 youths overall in the study, and only 1 in 21 adolescents, according to Scott E. Hadland, MD, MPH, MS, of Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, and coinvestigators.

These findings highlight a crucial need to improve care of youths with opioid use disorder (OUD) and enhance retention in treatment, Dr. Hadland and coauthors said in JAMA Pediatrics.

“As deaths from overdose increase among U.S. youths, it is vital that clinicians, researchers, and policy makers ensure that access to evidence-based OUD medications for young people remains a national priority,” they said. Their study, based on Medicaid enrollment and claims data from 11 states, included 4,837 youths aged 13-22 years with a diagnosis of OUD. The median age at diagnosis was 20 years, and 2,752 of the youths were female.

Timely buprenorphine, naltrexone, or methadone were received by just 34 out of 728 adolescents (4.7%) and 1,105 out of 4,109 young adults (27%). Most received buprenorphine (82%), while 12% got naltrexone and 6% got methadone. Treatment was considered timely if received within 3 months, and most patients received this treatment within 1 month.

Youths who received timely OUD medications were more likely to be retained in addiction treatment, the investigators found. Median retention in care was 67 days for youths who received behavioral health services only, compared with 123 days for those who received buprenorphine, 150 days for naltrexone, and 324 days for methadone.

Youths receiving buprenorphine were 42% less likely to discontinue addiction treatment, compared with those receiving behavioral services only, while those receiving naltrexone were 46% less likely to discontinue, and those receiving methadone were 68% less likely to discontinue.

Similarly, median duration of behavioral health services was longer for youths who received OUD medications versus those who did not, they added.

Retention in care is critical to successful addiction treatment, according to Dr. Hadland and coauthors.“Even when patients do not reduce their substance use, individuals engaged and retained in care can receive harm-reduction services and treatment of comorbid medical and psychiatric conditions.”

The benefit of that approach is affirmed by results of a recent meta-analysis in adults showing that staying in treatment was associated with reduced all-cause mortality and mortality from overdose, they said.

Dr. Hadland and coauthors reported no conflicts of interest related to the study. Researchers were supported by grants from the National Institutes of Health/National Institute on Drug Abuse (NIH/NIDA), a grant from the NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Thrasher Research Fund Early Career Award, and the Academic Pediatric Association Young Investigator Award.
 

SOURCE: Hadland SE, et al. JAMA Pediatr. 2018 Sep 10. doi:10.1001/jamapediatrics.2018.2143.

Youths with opioid use disorder (OUD) are more likely to remain in care if they receive medications to treat the condition, but very few are receiving them, results of a retrospective cohort study suggest.

Hailshadow/iStock/Getty Images

Prescribing buprenorphine, naltrexone, or methadone soon after an OUD diagnosis in this study was associated with increased retention in care for adolescents and young adults.

However, medications were provided to just 1 in 4 youths overall in the study, and only 1 in 21 adolescents, according to Scott E. Hadland, MD, MPH, MS, of Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, and coinvestigators.

These findings highlight a crucial need to improve care of youths with opioid use disorder (OUD) and enhance retention in treatment, Dr. Hadland and coauthors said in JAMA Pediatrics.

“As deaths from overdose increase among U.S. youths, it is vital that clinicians, researchers, and policy makers ensure that access to evidence-based OUD medications for young people remains a national priority,” they said. Their study, based on Medicaid enrollment and claims data from 11 states, included 4,837 youths aged 13-22 years with a diagnosis of OUD. The median age at diagnosis was 20 years, and 2,752 of the youths were female.

Timely buprenorphine, naltrexone, or methadone were received by just 34 out of 728 adolescents (4.7%) and 1,105 out of 4,109 young adults (27%). Most received buprenorphine (82%), while 12% got naltrexone and 6% got methadone. Treatment was considered timely if received within 3 months, and most patients received this treatment within 1 month.

Youths who received timely OUD medications were more likely to be retained in addiction treatment, the investigators found. Median retention in care was 67 days for youths who received behavioral health services only, compared with 123 days for those who received buprenorphine, 150 days for naltrexone, and 324 days for methadone.

Youths receiving buprenorphine were 42% less likely to discontinue addiction treatment, compared with those receiving behavioral services only, while those receiving naltrexone were 46% less likely to discontinue, and those receiving methadone were 68% less likely to discontinue.

Similarly, median duration of behavioral health services was longer for youths who received OUD medications versus those who did not, they added.

Retention in care is critical to successful addiction treatment, according to Dr. Hadland and coauthors.“Even when patients do not reduce their substance use, individuals engaged and retained in care can receive harm-reduction services and treatment of comorbid medical and psychiatric conditions.”

The benefit of that approach is affirmed by results of a recent meta-analysis in adults showing that staying in treatment was associated with reduced all-cause mortality and mortality from overdose, they said.

Dr. Hadland and coauthors reported no conflicts of interest related to the study. Researchers were supported by grants from the National Institutes of Health/National Institute on Drug Abuse (NIH/NIDA), a grant from the NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Thrasher Research Fund Early Career Award, and the Academic Pediatric Association Young Investigator Award.
 

SOURCE: Hadland SE, et al. JAMA Pediatr. 2018 Sep 10. doi:10.1001/jamapediatrics.2018.2143.

Youths with opioid use disorder (OUD) are more likely to remain in care if they receive medications to treat the condition, but very few are receiving them, results of a retrospective cohort study suggest.

Hailshadow/iStock/Getty Images

Prescribing buprenorphine, naltrexone, or methadone soon after an OUD diagnosis in this study was associated with increased retention in care for adolescents and young adults.

However, medications were provided to just 1 in 4 youths overall in the study, and only 1 in 21 adolescents, according to Scott E. Hadland, MD, MPH, MS, of Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, and coinvestigators.

These findings highlight a crucial need to improve care of youths with opioid use disorder (OUD) and enhance retention in treatment, Dr. Hadland and coauthors said in JAMA Pediatrics.

“As deaths from overdose increase among U.S. youths, it is vital that clinicians, researchers, and policy makers ensure that access to evidence-based OUD medications for young people remains a national priority,” they said. Their study, based on Medicaid enrollment and claims data from 11 states, included 4,837 youths aged 13-22 years with a diagnosis of OUD. The median age at diagnosis was 20 years, and 2,752 of the youths were female.

Timely buprenorphine, naltrexone, or methadone were received by just 34 out of 728 adolescents (4.7%) and 1,105 out of 4,109 young adults (27%). Most received buprenorphine (82%), while 12% got naltrexone and 6% got methadone. Treatment was considered timely if received within 3 months, and most patients received this treatment within 1 month.

Youths who received timely OUD medications were more likely to be retained in addiction treatment, the investigators found. Median retention in care was 67 days for youths who received behavioral health services only, compared with 123 days for those who received buprenorphine, 150 days for naltrexone, and 324 days for methadone.

Youths receiving buprenorphine were 42% less likely to discontinue addiction treatment, compared with those receiving behavioral services only, while those receiving naltrexone were 46% less likely to discontinue, and those receiving methadone were 68% less likely to discontinue.

Similarly, median duration of behavioral health services was longer for youths who received OUD medications versus those who did not, they added.

Retention in care is critical to successful addiction treatment, according to Dr. Hadland and coauthors.“Even when patients do not reduce their substance use, individuals engaged and retained in care can receive harm-reduction services and treatment of comorbid medical and psychiatric conditions.”

The benefit of that approach is affirmed by results of a recent meta-analysis in adults showing that staying in treatment was associated with reduced all-cause mortality and mortality from overdose, they said.

Dr. Hadland and coauthors reported no conflicts of interest related to the study. Researchers were supported by grants from the National Institutes of Health/National Institute on Drug Abuse (NIH/NIDA), a grant from the NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Thrasher Research Fund Early Career Award, and the Academic Pediatric Association Young Investigator Award.
 

SOURCE: Hadland SE, et al. JAMA Pediatr. 2018 Sep 10. doi:10.1001/jamapediatrics.2018.2143.

ESTES PARK, COLO. – The first-line medications for anxiety disorders are the same ones used for depression – the SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) – but the dosing strategies are quite different, Elizabeth L. Lowdermilk, MD, said at a conference on internal medicine sponsored by the University of Colorado.

MDedge News

“We know that folks with anxiety disorders tend to need the higher doses. They just need to get there a little more slowly,” according to Dr. Lowdermilk, a psychiatrist at the university and medical director of outpatient psychiatry at Denver Health.

“The trick is not what drug you use, it’s what dose you started at. For example, when I start sertraline for depression I start it at 50 mg per day. When I start it for anxiety I start it at 25. I just give it a week or 2 at 25 and then I double it to 50. And then I keep going, titrating over 2-3 months to a high or maximum dose,” she explained.

The rapidity of response to the SSRIs and SNRIs is quite different, too. When patients are started on one of these agents as treatment for depression, they can expect that it will take at least 4-6 weeks and maybe as long as 12 weeks before they experience the full therapeutic effect. Not so when the same drugs are used to treat anxiety disorders.

“The anxiolytic effect seems to be more robust sooner. Really, people start noticing something within the first couple days to a week. And they will keep getting better, which people love,” Dr. Lowdermilk said.

One of the early positive effects of SSRI/SNRI therapy that patients can be advised to be on the lookout for is “the Teflon mind,” she said.

“It’s not that the worried thoughts won’t arise, but they’re going to slide out faster and patients are going to be able to shift their focus back to where they want it to be and move forward,” the psychiatrist explained.

Other positive treatment effects include reductions in irritability, anger, perseverative thoughts, restlessness, and physical tension, along with improved sleep.

How to monitor patient response

The most practical anxiety rating scale for busy primary care physicians with tight office visit scheduling is the seven-item Generalized Anxiety Disorder Assessment, or GAD 7. It can be used repeatedly to follow a patient’s treatment response.

“While technically it is picking up the symptoms of GAD, because there are so many overlapping symptoms in all of the anxiety disorders this is going to give you a sense of whether someone is getting better. It won’t pick up their nightmares if they have PTSD, and it won’t necessarily pick up their checking behaviors if they have obsessive-compulsive disorder – you can ask them quickly about that,” she said.
 

Augmenting an SSRI/SNRI

Be advised: While some patients with an anxiety disorder will experience complete resolution of symptoms on the maximum approved dose of an SSRI/SNRI, such as 200 mg/day of sertraline (Zoloft), lots of patients will have only a partial response. The next move is not to add a second antidepressant, it’s to augment the high-dose antidepressant the patient is already on with something else. Dr. Lowdermilk highlighted the best and worst strategies:

• Hydroxyzine: This drug, approved by the Food and Drug Administration for treatment of panic attacks at 25-50 mg up to four times per day, has sedating side effects that help with sleep issues.

“We use a lot of this,” Dr. Lowdermilk said.

Hydroxyzine (Vistaril) can be dosed on a fixed schedule or as needed. She strongly favors scheduled dosing. “It’s better to use drugs to reduce anxiety tone, then teach skills to cope with anxiety. As needed treatment subtly teaches patients to take a pill if they have breakthrough symptoms.”

• Buspirone: It takes high doses of this medication to get a robust anxiolytic response. Dr. Lowdermilk recommends starting at 5 mg three times daily and increasing the total daily dose by 15 mg every 2 weeks up to a maximum of 60 mg.

“Buspirone isn’t the strongest medication out there, but it can help. I personally don’t stop until I’m at least at 30 mg per day,” she said.

The drug is especially handy as monotherapy in patients with mild to moderate anxiety who can’t tolerate serotonergic medications well. Also, at higher doses buspirone (Buspar) may reduce the sexual side effects of a concomitant serotonergic agent.

• Gabapentin: Dr. Lowdermilk often turns to this drug off label as an SSRI/SNRI augmentation strategy, starting at 100-300 mg three times daily and increasing over the same time frame as for neuropathic pain up to a maximum total daily dose of 3,600 mg. Like hydroxyzine, it helps with sleep.
• Atypical antipsychotics: Reserve these for patients with an inadequate response to maximum-dose SSRI/SNRI. There is some evidence of efficacy for low-dose risperidone (Risperdal) at 1-2 mg/day, quetiapine(Seroquel) at 50-100 mg, and aripiprazole (Abilify) at 2-5 mg. Because of the risks of metabolic side effects and tardive dyskinesia, it’s best to evaluate the drug’s effectiveness after 2-4 weeks and consider stopping if there is no clinical improvement.
• Benzodiazepines: Yes, they are approved for treatment of anxiety disorders. Nevertheless, Dr. Lowdermilk advises against their as routine practice.

“I want to acknowledge that they really do work for anxiety and there are times you might want to consider them. But we are almost never initiating benzodiazepines anymore. We are learning that they cause more problems than not. What I’ve found over the years is short bursts of use are not short. Patients tend to come back and want more,” according to the psychiatrist.

She is not convinced about the claimed link to dementia, but she does believe long-term use of benzodiazepines is associated with memory and balance problems as well as slowed reaction time. If they are going to be used to treat anxiety disorders, it’s best to turn to a longer-acting agent such as clonazepam (Klonopin) or extended-release alprazolam (Xanax XR), which keep the anxiety tone down without producing the euphoria of short-acting benzodiazepines.

• Behavioral therapies: “I really do think that the combination of medication and behavioral therapy is the best approach,” Dr. Lowdermilk said.

Consider referring patients with a problematic anxiety disorder to a behavioral therapist skilled in cognitive behavioral therapy, exposure therapy, response prevention therapy, or eye movement desensitization and reprocessing.

She reported having no financial conflicts regarding her presentation.

[email protected]

ESTES PARK, COLO. – The first-line medications for anxiety disorders are the same ones used for depression – the SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) – but the dosing strategies are quite different, Elizabeth L. Lowdermilk, MD, said at a conference on internal medicine sponsored by the University of Colorado.

MDedge News

“We know that folks with anxiety disorders tend to need the higher doses. They just need to get there a little more slowly,” according to Dr. Lowdermilk, a psychiatrist at the university and medical director of outpatient psychiatry at Denver Health.

“The trick is not what drug you use, it’s what dose you started at. For example, when I start sertraline for depression I start it at 50 mg per day. When I start it for anxiety I start it at 25. I just give it a week or 2 at 25 and then I double it to 50. And then I keep going, titrating over 2-3 months to a high or maximum dose,” she explained.

The rapidity of response to the SSRIs and SNRIs is quite different, too. When patients are started on one of these agents as treatment for depression, they can expect that it will take at least 4-6 weeks and maybe as long as 12 weeks before they experience the full therapeutic effect. Not so when the same drugs are used to treat anxiety disorders.

“The anxiolytic effect seems to be more robust sooner. Really, people start noticing something within the first couple days to a week. And they will keep getting better, which people love,” Dr. Lowdermilk said.

One of the early positive effects of SSRI/SNRI therapy that patients can be advised to be on the lookout for is “the Teflon mind,” she said.

“It’s not that the worried thoughts won’t arise, but they’re going to slide out faster and patients are going to be able to shift their focus back to where they want it to be and move forward,” the psychiatrist explained.

Other positive treatment effects include reductions in irritability, anger, perseverative thoughts, restlessness, and physical tension, along with improved sleep.

How to monitor patient response

The most practical anxiety rating scale for busy primary care physicians with tight office visit scheduling is the seven-item Generalized Anxiety Disorder Assessment, or GAD 7. It can be used repeatedly to follow a patient’s treatment response.

“While technically it is picking up the symptoms of GAD, because there are so many overlapping symptoms in all of the anxiety disorders this is going to give you a sense of whether someone is getting better. It won’t pick up their nightmares if they have PTSD, and it won’t necessarily pick up their checking behaviors if they have obsessive-compulsive disorder – you can ask them quickly about that,” she said.
 

Augmenting an SSRI/SNRI

Be advised: While some patients with an anxiety disorder will experience complete resolution of symptoms on the maximum approved dose of an SSRI/SNRI, such as 200 mg/day of sertraline (Zoloft), lots of patients will have only a partial response. The next move is not to add a second antidepressant, it’s to augment the high-dose antidepressant the patient is already on with something else. Dr. Lowdermilk highlighted the best and worst strategies:

• Hydroxyzine: This drug, approved by the Food and Drug Administration for treatment of panic attacks at 25-50 mg up to four times per day, has sedating side effects that help with sleep issues.

“We use a lot of this,” Dr. Lowdermilk said.

Hydroxyzine (Vistaril) can be dosed on a fixed schedule or as needed. She strongly favors scheduled dosing. “It’s better to use drugs to reduce anxiety tone, then teach skills to cope with anxiety. As needed treatment subtly teaches patients to take a pill if they have breakthrough symptoms.”

• Buspirone: It takes high doses of this medication to get a robust anxiolytic response. Dr. Lowdermilk recommends starting at 5 mg three times daily and increasing the total daily dose by 15 mg every 2 weeks up to a maximum of 60 mg.

“Buspirone isn’t the strongest medication out there, but it can help. I personally don’t stop until I’m at least at 30 mg per day,” she said.

The drug is especially handy as monotherapy in patients with mild to moderate anxiety who can’t tolerate serotonergic medications well. Also, at higher doses buspirone (Buspar) may reduce the sexual side effects of a concomitant serotonergic agent.

• Gabapentin: Dr. Lowdermilk often turns to this drug off label as an SSRI/SNRI augmentation strategy, starting at 100-300 mg three times daily and increasing over the same time frame as for neuropathic pain up to a maximum total daily dose of 3,600 mg. Like hydroxyzine, it helps with sleep.
• Atypical antipsychotics: Reserve these for patients with an inadequate response to maximum-dose SSRI/SNRI. There is some evidence of efficacy for low-dose risperidone (Risperdal) at 1-2 mg/day, quetiapine(Seroquel) at 50-100 mg, and aripiprazole (Abilify) at 2-5 mg. Because of the risks of metabolic side effects and tardive dyskinesia, it’s best to evaluate the drug’s effectiveness after 2-4 weeks and consider stopping if there is no clinical improvement.
• Benzodiazepines: Yes, they are approved for treatment of anxiety disorders. Nevertheless, Dr. Lowdermilk advises against their as routine practice.

“I want to acknowledge that they really do work for anxiety and there are times you might want to consider them. But we are almost never initiating benzodiazepines anymore. We are learning that they cause more problems than not. What I’ve found over the years is short bursts of use are not short. Patients tend to come back and want more,” according to the psychiatrist.

She is not convinced about the claimed link to dementia, but she does believe long-term use of benzodiazepines is associated with memory and balance problems as well as slowed reaction time. If they are going to be used to treat anxiety disorders, it’s best to turn to a longer-acting agent such as clonazepam (Klonopin) or extended-release alprazolam (Xanax XR), which keep the anxiety tone down without producing the euphoria of short-acting benzodiazepines.

• Behavioral therapies: “I really do think that the combination of medication and behavioral therapy is the best approach,” Dr. Lowdermilk said.

Consider referring patients with a problematic anxiety disorder to a behavioral therapist skilled in cognitive behavioral therapy, exposure therapy, response prevention therapy, or eye movement desensitization and reprocessing.

She reported having no financial conflicts regarding her presentation.

[email protected]

ESTES PARK, COLO. – The first-line medications for anxiety disorders are the same ones used for depression – the SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) – but the dosing strategies are quite different, Elizabeth L. Lowdermilk, MD, said at a conference on internal medicine sponsored by the University of Colorado.

MDedge News

“We know that folks with anxiety disorders tend to need the higher doses. They just need to get there a little more slowly,” according to Dr. Lowdermilk, a psychiatrist at the university and medical director of outpatient psychiatry at Denver Health.

“The trick is not what drug you use, it’s what dose you started at. For example, when I start sertraline for depression I start it at 50 mg per day. When I start it for anxiety I start it at 25. I just give it a week or 2 at 25 and then I double it to 50. And then I keep going, titrating over 2-3 months to a high or maximum dose,” she explained.

The rapidity of response to the SSRIs and SNRIs is quite different, too. When patients are started on one of these agents as treatment for depression, they can expect that it will take at least 4-6 weeks and maybe as long as 12 weeks before they experience the full therapeutic effect. Not so when the same drugs are used to treat anxiety disorders.

“The anxiolytic effect seems to be more robust sooner. Really, people start noticing something within the first couple days to a week. And they will keep getting better, which people love,” Dr. Lowdermilk said.

One of the early positive effects of SSRI/SNRI therapy that patients can be advised to be on the lookout for is “the Teflon mind,” she said.

“It’s not that the worried thoughts won’t arise, but they’re going to slide out faster and patients are going to be able to shift their focus back to where they want it to be and move forward,” the psychiatrist explained.

Other positive treatment effects include reductions in irritability, anger, perseverative thoughts, restlessness, and physical tension, along with improved sleep.

How to monitor patient response

The most practical anxiety rating scale for busy primary care physicians with tight office visit scheduling is the seven-item Generalized Anxiety Disorder Assessment, or GAD 7. It can be used repeatedly to follow a patient’s treatment response.

“While technically it is picking up the symptoms of GAD, because there are so many overlapping symptoms in all of the anxiety disorders this is going to give you a sense of whether someone is getting better. It won’t pick up their nightmares if they have PTSD, and it won’t necessarily pick up their checking behaviors if they have obsessive-compulsive disorder – you can ask them quickly about that,” she said.
 

Augmenting an SSRI/SNRI

Be advised: While some patients with an anxiety disorder will experience complete resolution of symptoms on the maximum approved dose of an SSRI/SNRI, such as 200 mg/day of sertraline (Zoloft), lots of patients will have only a partial response. The next move is not to add a second antidepressant, it’s to augment the high-dose antidepressant the patient is already on with something else. Dr. Lowdermilk highlighted the best and worst strategies:

• Hydroxyzine: This drug, approved by the Food and Drug Administration for treatment of panic attacks at 25-50 mg up to four times per day, has sedating side effects that help with sleep issues.

“We use a lot of this,” Dr. Lowdermilk said.

Hydroxyzine (Vistaril) can be dosed on a fixed schedule or as needed. She strongly favors scheduled dosing. “It’s better to use drugs to reduce anxiety tone, then teach skills to cope with anxiety. As needed treatment subtly teaches patients to take a pill if they have breakthrough symptoms.”

• Buspirone: It takes high doses of this medication to get a robust anxiolytic response. Dr. Lowdermilk recommends starting at 5 mg three times daily and increasing the total daily dose by 15 mg every 2 weeks up to a maximum of 60 mg.

“Buspirone isn’t the strongest medication out there, but it can help. I personally don’t stop until I’m at least at 30 mg per day,” she said.

The drug is especially handy as monotherapy in patients with mild to moderate anxiety who can’t tolerate serotonergic medications well. Also, at higher doses buspirone (Buspar) may reduce the sexual side effects of a concomitant serotonergic agent.

• Gabapentin: Dr. Lowdermilk often turns to this drug off label as an SSRI/SNRI augmentation strategy, starting at 100-300 mg three times daily and increasing over the same time frame as for neuropathic pain up to a maximum total daily dose of 3,600 mg. Like hydroxyzine, it helps with sleep.
• Atypical antipsychotics: Reserve these for patients with an inadequate response to maximum-dose SSRI/SNRI. There is some evidence of efficacy for low-dose risperidone (Risperdal) at 1-2 mg/day, quetiapine(Seroquel) at 50-100 mg, and aripiprazole (Abilify) at 2-5 mg. Because of the risks of metabolic side effects and tardive dyskinesia, it’s best to evaluate the drug’s effectiveness after 2-4 weeks and consider stopping if there is no clinical improvement.
• Benzodiazepines: Yes, they are approved for treatment of anxiety disorders. Nevertheless, Dr. Lowdermilk advises against their as routine practice.

“I want to acknowledge that they really do work for anxiety and there are times you might want to consider them. But we are almost never initiating benzodiazepines anymore. We are learning that they cause more problems than not. What I’ve found over the years is short bursts of use are not short. Patients tend to come back and want more,” according to the psychiatrist.

She is not convinced about the claimed link to dementia, but she does believe long-term use of benzodiazepines is associated with memory and balance problems as well as slowed reaction time. If they are going to be used to treat anxiety disorders, it’s best to turn to a longer-acting agent such as clonazepam (Klonopin) or extended-release alprazolam (Xanax XR), which keep the anxiety tone down without producing the euphoria of short-acting benzodiazepines.

• Behavioral therapies: “I really do think that the combination of medication and behavioral therapy is the best approach,” Dr. Lowdermilk said.

Consider referring patients with a problematic anxiety disorder to a behavioral therapist skilled in cognitive behavioral therapy, exposure therapy, response prevention therapy, or eye movement desensitization and reprocessing.

She reported having no financial conflicts regarding her presentation.

[email protected]

Immunization resources

Current recommended adult (anyone over 18 years old) immunization schedule

ACOG Immunization Champions (ACOG members who have demonstrated exceptional progress in increasing immunization rates among adults and pregnant women in their communities through leadership, innovation, collaboration, and educational activities aimed at following ACOG and CDC guidance.)

Summary of Maternal Immunization Recommendations is a provider resource from ACOG and the Centers for Disease Control and Prevention.

Maternal Immunization Toolkit contains materials, including the Vaccines During Pregnancy Poster, to support ObGyns on recommending the influenza vaccine and the Tdap vaccine to all pregnant patients.

Influenza Immunization During Pregnancy Toolkit

Tdap Immunization Toolkit

Immunization resources

Current recommended adult (anyone over 18 years old) immunization schedule

ACOG Immunization Champions (ACOG members who have demonstrated exceptional progress in increasing immunization rates among adults and pregnant women in their communities through leadership, innovation, collaboration, and educational activities aimed at following ACOG and CDC guidance.)

Summary of Maternal Immunization Recommendations is a provider resource from ACOG and the Centers for Disease Control and Prevention.

Maternal Immunization Toolkit contains materials, including the Vaccines During Pregnancy Poster, to support ObGyns on recommending the influenza vaccine and the Tdap vaccine to all pregnant patients.

Influenza Immunization During Pregnancy Toolkit

Tdap Immunization Toolkit

Immunization resources

Current recommended adult (anyone over 18 years old) immunization schedule

ACOG Immunization Champions (ACOG members who have demonstrated exceptional progress in increasing immunization rates among adults and pregnant women in their communities through leadership, innovation, collaboration, and educational activities aimed at following ACOG and CDC guidance.)

Summary of Maternal Immunization Recommendations is a provider resource from ACOG and the Centers for Disease Control and Prevention.

Maternal Immunization Toolkit contains materials, including the Vaccines During Pregnancy Poster, to support ObGyns on recommending the influenza vaccine and the Tdap vaccine to all pregnant patients.

Influenza Immunization During Pregnancy Toolkit

Tdap Immunization Toolkit

Coding. Practice expenses. Supervised Exercise Therapy. The vascular lab. Medicare reimbursement (including MACRA, MIPS, APMs and QPP). All these topics and more are part of a vascular surgeon's life and livelihood. Vascular surgery trainees interested in health policy and advocacy issues related to vascular surgery are encouraged to apply for the SVS Vascular Surgery Trainee Advocacy Travel Scholarship. Submissions are due by Oct. 31. The winner receives $1,500 to defray travel costs to Washington, D.C., to participate in Capitol Hill visits and learn more about SVS' health policy and advocacy activities.

Coding. Practice expenses. Supervised Exercise Therapy. The vascular lab. Medicare reimbursement (including MACRA, MIPS, APMs and QPP). All these topics and more are part of a vascular surgeon's life and livelihood. Vascular surgery trainees interested in health policy and advocacy issues related to vascular surgery are encouraged to apply for the SVS Vascular Surgery Trainee Advocacy Travel Scholarship. Submissions are due by Oct. 31. The winner receives $1,500 to defray travel costs to Washington, D.C., to participate in Capitol Hill visits and learn more about SVS' health policy and advocacy activities.

Coding. Practice expenses. Supervised Exercise Therapy. The vascular lab. Medicare reimbursement (including MACRA, MIPS, APMs and QPP). All these topics and more are part of a vascular surgeon's life and livelihood. Vascular surgery trainees interested in health policy and advocacy issues related to vascular surgery are encouraged to apply for the SVS Vascular Surgery Trainee Advocacy Travel Scholarship. Submissions are due by Oct. 31. The winner receives $1,500 to defray travel costs to Washington, D.C., to participate in Capitol Hill visits and learn more about SVS' health policy and advocacy activities.

It’s Vascular Nurses Week this week, and as part of the celebration, the SVS is inviting Society for Vascular Nursing members to join the SVS as affiliate members. Applicants will receive a 50 percent discount through Dec. 1. Email CVs and the completed membership form to [email protected].

It’s Vascular Nurses Week this week, and as part of the celebration, the SVS is inviting Society for Vascular Nursing members to join the SVS as affiliate members. Applicants will receive a 50 percent discount through Dec. 1. Email CVs and the completed membership form to [email protected].

It’s Vascular Nurses Week this week, and as part of the celebration, the SVS is inviting Society for Vascular Nursing members to join the SVS as affiliate members. Applicants will receive a 50 percent discount through Dec. 1. Email CVs and the completed membership form to [email protected].

BOSTON – The use of an intravascular ultrasound (IVUS)–based scoring system could predict stent failure at 2 years in the treatment of May-Thurner syndrome, according to Steven D. Abramowitz, MD, of the MedStar Washington Hospital Center, Washington, and his colleagues.

Martin Allred/Nationwide Photographers

Dr. Abramowitz presented their research in the Vascular and Endovascular Society (VESS) sessions held at the Vascular Annual Meeting.

“IVUS has become an important adjuvant diagnostic tool in the treatment of deep venous disease, and as such may provide a useful assessment and predictive tool for treatment success in stenting of May-Thurner syndrome,” said Dr. Abramowitz.

In their study, 118 consecutive patients with May-Thurner syndrome underwent IVUS-guided stent placement from April 2009 through May 2015 at two collaborating institutions. Patients had a mean age of 46 years and included 86 (73%) women. At the time of treatment, 45, 30, 25, and 18 patients had Clinical Etiology Anatomy Pathophysiology disease 3, 4, 5, and 6, respectively.

Dr. Abramowitz described how he and his colleagues derived an IVUS-driven scoring system to assess the following categories of May-Thurner syndrome (nonocclusive or occlusive), disease chronicity (nonthrombotic, acute, or chronic), venous disease length (less than 180 mm or greater than 181 mm), venous inflow compliance (presence or absence of respiratory variation), iliocaval confluence disease involvement (present or absent), iliocaval con-fluence stenting obligation (stented or spared), and presence of perivenous collaterals before and after stenting (none or resolved).

Six of the categories were scored with 0 or 1 and one category was scored with 0, 1, or 2. Scores were tabulated for each patient at the time of initial intervention.

All 118 (100%) patients received anticoagulation and 78 (66%) were on an antiplatelet agent. Thirty-eight (32%) developed moderate in-stent stenosis, required thrombolysis, or underwent additional stenting procedures and were considered treatment failures during the observed period.

Eighty patients (68%) required no additional intervention and were considered treatment successes. The mean IVUS score for all patients was 5.22. The mean IVUS score in the treatment failure cohort was 5.64 compared with a score of 4.67 in the treatment success group, a significant difference. Patients with a score above 4 on this 7-point scale had an increased relative risk (1.6) of stent failure at 2 years.

“An IVUS-driven scoring system score of 4 or greater during initial intervention for May-Thurner syndrome predicts failure at 2 years. Additional treatment modalities should be considered at implantation to prevent failure,” said Dr. Abramowitz.

In an interview, Dr. Abramowitz added: “There is an emerging body of research regarding outcomes of deep venous intervention. However, we are still looking to generate clinically relevant data that will help guide interventionists to achieve durable technical success and long-term positive clinical outcomes for our patients.

“At this time, there is very little data to help correlate what physicians see on venography and IVUS during the treatment of May-Thurner Lesions. This data is hopefully the first step in allowing us to guide intra-operative decision making. IVUS is an excellent tool that has been proven by other studies to aid in the diagnosis and management of venous disease. With this data we also hope that it becomes a drive of patient management as well. Ideally, this data will transition into also guiding anticoagulation management, postoperative surveillance strategies and outcomes stratification for patients,” Dr. Abramowitz concluded.

[email protected]

BOSTON – The use of an intravascular ultrasound (IVUS)–based scoring system could predict stent failure at 2 years in the treatment of May-Thurner syndrome, according to Steven D. Abramowitz, MD, of the MedStar Washington Hospital Center, Washington, and his colleagues.

Martin Allred/Nationwide Photographers

Dr. Abramowitz presented their research in the Vascular and Endovascular Society (VESS) sessions held at the Vascular Annual Meeting.

“IVUS has become an important adjuvant diagnostic tool in the treatment of deep venous disease, and as such may provide a useful assessment and predictive tool for treatment success in stenting of May-Thurner syndrome,” said Dr. Abramowitz.

In their study, 118 consecutive patients with May-Thurner syndrome underwent IVUS-guided stent placement from April 2009 through May 2015 at two collaborating institutions. Patients had a mean age of 46 years and included 86 (73%) women. At the time of treatment, 45, 30, 25, and 18 patients had Clinical Etiology Anatomy Pathophysiology disease 3, 4, 5, and 6, respectively.

Dr. Abramowitz described how he and his colleagues derived an IVUS-driven scoring system to assess the following categories of May-Thurner syndrome (nonocclusive or occlusive), disease chronicity (nonthrombotic, acute, or chronic), venous disease length (less than 180 mm or greater than 181 mm), venous inflow compliance (presence or absence of respiratory variation), iliocaval confluence disease involvement (present or absent), iliocaval con-fluence stenting obligation (stented or spared), and presence of perivenous collaterals before and after stenting (none or resolved).

Six of the categories were scored with 0 or 1 and one category was scored with 0, 1, or 2. Scores were tabulated for each patient at the time of initial intervention.

All 118 (100%) patients received anticoagulation and 78 (66%) were on an antiplatelet agent. Thirty-eight (32%) developed moderate in-stent stenosis, required thrombolysis, or underwent additional stenting procedures and were considered treatment failures during the observed period.

Eighty patients (68%) required no additional intervention and were considered treatment successes. The mean IVUS score for all patients was 5.22. The mean IVUS score in the treatment failure cohort was 5.64 compared with a score of 4.67 in the treatment success group, a significant difference. Patients with a score above 4 on this 7-point scale had an increased relative risk (1.6) of stent failure at 2 years.

“An IVUS-driven scoring system score of 4 or greater during initial intervention for May-Thurner syndrome predicts failure at 2 years. Additional treatment modalities should be considered at implantation to prevent failure,” said Dr. Abramowitz.

In an interview, Dr. Abramowitz added: “There is an emerging body of research regarding outcomes of deep venous intervention. However, we are still looking to generate clinically relevant data that will help guide interventionists to achieve durable technical success and long-term positive clinical outcomes for our patients.

“At this time, there is very little data to help correlate what physicians see on venography and IVUS during the treatment of May-Thurner Lesions. This data is hopefully the first step in allowing us to guide intra-operative decision making. IVUS is an excellent tool that has been proven by other studies to aid in the diagnosis and management of venous disease. With this data we also hope that it becomes a drive of patient management as well. Ideally, this data will transition into also guiding anticoagulation management, postoperative surveillance strategies and outcomes stratification for patients,” Dr. Abramowitz concluded.

[email protected]

BOSTON – The use of an intravascular ultrasound (IVUS)–based scoring system could predict stent failure at 2 years in the treatment of May-Thurner syndrome, according to Steven D. Abramowitz, MD, of the MedStar Washington Hospital Center, Washington, and his colleagues.

Martin Allred/Nationwide Photographers

Dr. Abramowitz presented their research in the Vascular and Endovascular Society (VESS) sessions held at the Vascular Annual Meeting.

“IVUS has become an important adjuvant diagnostic tool in the treatment of deep venous disease, and as such may provide a useful assessment and predictive tool for treatment success in stenting of May-Thurner syndrome,” said Dr. Abramowitz.

In their study, 118 consecutive patients with May-Thurner syndrome underwent IVUS-guided stent placement from April 2009 through May 2015 at two collaborating institutions. Patients had a mean age of 46 years and included 86 (73%) women. At the time of treatment, 45, 30, 25, and 18 patients had Clinical Etiology Anatomy Pathophysiology disease 3, 4, 5, and 6, respectively.

Dr. Abramowitz described how he and his colleagues derived an IVUS-driven scoring system to assess the following categories of May-Thurner syndrome (nonocclusive or occlusive), disease chronicity (nonthrombotic, acute, or chronic), venous disease length (less than 180 mm or greater than 181 mm), venous inflow compliance (presence or absence of respiratory variation), iliocaval confluence disease involvement (present or absent), iliocaval con-fluence stenting obligation (stented or spared), and presence of perivenous collaterals before and after stenting (none or resolved).

Six of the categories were scored with 0 or 1 and one category was scored with 0, 1, or 2. Scores were tabulated for each patient at the time of initial intervention.

All 118 (100%) patients received anticoagulation and 78 (66%) were on an antiplatelet agent. Thirty-eight (32%) developed moderate in-stent stenosis, required thrombolysis, or underwent additional stenting procedures and were considered treatment failures during the observed period.

Eighty patients (68%) required no additional intervention and were considered treatment successes. The mean IVUS score for all patients was 5.22. The mean IVUS score in the treatment failure cohort was 5.64 compared with a score of 4.67 in the treatment success group, a significant difference. Patients with a score above 4 on this 7-point scale had an increased relative risk (1.6) of stent failure at 2 years.

“An IVUS-driven scoring system score of 4 or greater during initial intervention for May-Thurner syndrome predicts failure at 2 years. Additional treatment modalities should be considered at implantation to prevent failure,” said Dr. Abramowitz.

In an interview, Dr. Abramowitz added: “There is an emerging body of research regarding outcomes of deep venous intervention. However, we are still looking to generate clinically relevant data that will help guide interventionists to achieve durable technical success and long-term positive clinical outcomes for our patients.

“At this time, there is very little data to help correlate what physicians see on venography and IVUS during the treatment of May-Thurner Lesions. This data is hopefully the first step in allowing us to guide intra-operative decision making. IVUS is an excellent tool that has been proven by other studies to aid in the diagnosis and management of venous disease. With this data we also hope that it becomes a drive of patient management as well. Ideally, this data will transition into also guiding anticoagulation management, postoperative surveillance strategies and outcomes stratification for patients,” Dr. Abramowitz concluded.

[email protected]

Clinical question: Do factor Xa inhibitors reduce the incidence of strokes and systemic embolic events, compared with warfarin, in people with atrial fibrillation?

Background: Factor Xa inhibitors, called DOACs or direct-acting anticoagulants, and vitamin K antagonists (VKAs) are part of treatment guidelines for preventing stroke and systemic embolic events in people with atrial fibrillation (AF). This study assessed the effectiveness and safety of treatment with factor Xa inhibitors versus VKAs for preventing cerebral or systemic embolic events in AF.

Study design: Cochrane Review update.

Setting: Data obtained from trial registers of the Cochrane Central Register of Controlled Trials (August 2017), the Cochrane Heart Group and the Cochrane Stroke Group (September 2016), Embase (1980 to April 2017), and MEDLINE (1950 to April 2017). Authors also screened reference lists and contacted pharmaceutical companies, authors, and sponsors of relevant published trials.

Synopsis: The study included 42,084 participants from 10 trials with a diagnosis of AF who were eligible for long-term anticoagulation with warfarin (target INR 2-3).

The trials directly compared dose-adjusted warfarin with factor Xa inhibitors. Median follow-up ranged from 12 weeks to 1.9 years, and composite primary endpoint was all strokes (both ischemic and hemorrhagic) and non–central nervous systemic embolic events. Factor Xa inhibitor significantly decreased the number of strokes and systemic embolic events, compared with dose-adjusted warfarin (odds ratio, 0.81; 95% confidence interval, 0.72-0.91), reduced the number of major bleeding events (OR, 0.92; 95% CI, 0.63-1.34), and significantly reduced the risk of intracranial hemorrhage (OR, 0.56; 95% CI, 0.45-0.70). They also significantly reduced the number of all-cause deaths (OR, 0.88; 95% CI, 0.81-0.97). One limitation of this study is the heterogeneity and hence lower quality of evidence. This study shows a small net clinical benefit of using factor Xa inhibitors in AF because of a reduction in strokes and systemic embolic events and also a lower risk of bleeding (including intracranial hemorrhages), compared with using warfarin.

Bottom line: Patients with AF have a lower incidence of strokes and systemic embolic events when treated with factor Xa inhibitors, compared with those treated with warfarin.

Citation: Bruins Slot KM et al. Factor Xa inhibitors versus vitamin K antagonists for preventing cerebral or systemic embolism in patients with atrial fibrillation. Cochrane Database Syst Rev. 2018 Mar 6. doi: 10.1002/14651858.CD008980.pub3.

Dr. Veedu is a hospitalist and instructor in the division of hospital medicine at the University of Kentucky, Lexington.

Clinical question: Do factor Xa inhibitors reduce the incidence of strokes and systemic embolic events, compared with warfarin, in people with atrial fibrillation?

Background: Factor Xa inhibitors, called DOACs or direct-acting anticoagulants, and vitamin K antagonists (VKAs) are part of treatment guidelines for preventing stroke and systemic embolic events in people with atrial fibrillation (AF). This study assessed the effectiveness and safety of treatment with factor Xa inhibitors versus VKAs for preventing cerebral or systemic embolic events in AF.

Study design: Cochrane Review update.

Setting: Data obtained from trial registers of the Cochrane Central Register of Controlled Trials (August 2017), the Cochrane Heart Group and the Cochrane Stroke Group (September 2016), Embase (1980 to April 2017), and MEDLINE (1950 to April 2017). Authors also screened reference lists and contacted pharmaceutical companies, authors, and sponsors of relevant published trials.

Synopsis: The study included 42,084 participants from 10 trials with a diagnosis of AF who were eligible for long-term anticoagulation with warfarin (target INR 2-3).

The trials directly compared dose-adjusted warfarin with factor Xa inhibitors. Median follow-up ranged from 12 weeks to 1.9 years, and composite primary endpoint was all strokes (both ischemic and hemorrhagic) and non–central nervous systemic embolic events. Factor Xa inhibitor significantly decreased the number of strokes and systemic embolic events, compared with dose-adjusted warfarin (odds ratio, 0.81; 95% confidence interval, 0.72-0.91), reduced the number of major bleeding events (OR, 0.92; 95% CI, 0.63-1.34), and significantly reduced the risk of intracranial hemorrhage (OR, 0.56; 95% CI, 0.45-0.70). They also significantly reduced the number of all-cause deaths (OR, 0.88; 95% CI, 0.81-0.97). One limitation of this study is the heterogeneity and hence lower quality of evidence. This study shows a small net clinical benefit of using factor Xa inhibitors in AF because of a reduction in strokes and systemic embolic events and also a lower risk of bleeding (including intracranial hemorrhages), compared with using warfarin.

Bottom line: Patients with AF have a lower incidence of strokes and systemic embolic events when treated with factor Xa inhibitors, compared with those treated with warfarin.

Citation: Bruins Slot KM et al. Factor Xa inhibitors versus vitamin K antagonists for preventing cerebral or systemic embolism in patients with atrial fibrillation. Cochrane Database Syst Rev. 2018 Mar 6. doi: 10.1002/14651858.CD008980.pub3.

Dr. Veedu is a hospitalist and instructor in the division of hospital medicine at the University of Kentucky, Lexington.

Clinical question: Do factor Xa inhibitors reduce the incidence of strokes and systemic embolic events, compared with warfarin, in people with atrial fibrillation?

Background: Factor Xa inhibitors, called DOACs or direct-acting anticoagulants, and vitamin K antagonists (VKAs) are part of treatment guidelines for preventing stroke and systemic embolic events in people with atrial fibrillation (AF). This study assessed the effectiveness and safety of treatment with factor Xa inhibitors versus VKAs for preventing cerebral or systemic embolic events in AF.

Study design: Cochrane Review update.

Setting: Data obtained from trial registers of the Cochrane Central Register of Controlled Trials (August 2017), the Cochrane Heart Group and the Cochrane Stroke Group (September 2016), Embase (1980 to April 2017), and MEDLINE (1950 to April 2017). Authors also screened reference lists and contacted pharmaceutical companies, authors, and sponsors of relevant published trials.

Synopsis: The study included 42,084 participants from 10 trials with a diagnosis of AF who were eligible for long-term anticoagulation with warfarin (target INR 2-3).

The trials directly compared dose-adjusted warfarin with factor Xa inhibitors. Median follow-up ranged from 12 weeks to 1.9 years, and composite primary endpoint was all strokes (both ischemic and hemorrhagic) and non–central nervous systemic embolic events. Factor Xa inhibitor significantly decreased the number of strokes and systemic embolic events, compared with dose-adjusted warfarin (odds ratio, 0.81; 95% confidence interval, 0.72-0.91), reduced the number of major bleeding events (OR, 0.92; 95% CI, 0.63-1.34), and significantly reduced the risk of intracranial hemorrhage (OR, 0.56; 95% CI, 0.45-0.70). They also significantly reduced the number of all-cause deaths (OR, 0.88; 95% CI, 0.81-0.97). One limitation of this study is the heterogeneity and hence lower quality of evidence. This study shows a small net clinical benefit of using factor Xa inhibitors in AF because of a reduction in strokes and systemic embolic events and also a lower risk of bleeding (including intracranial hemorrhages), compared with using warfarin.

Bottom line: Patients with AF have a lower incidence of strokes and systemic embolic events when treated with factor Xa inhibitors, compared with those treated with warfarin.

Citation: Bruins Slot KM et al. Factor Xa inhibitors versus vitamin K antagonists for preventing cerebral or systemic embolism in patients with atrial fibrillation. Cochrane Database Syst Rev. 2018 Mar 6. doi: 10.1002/14651858.CD008980.pub3.

Dr. Veedu is a hospitalist and instructor in the division of hospital medicine at the University of Kentucky, Lexington.

Why do patients no-show?

The reasons are, obviously, widely variable among patients and circumstances. Some are more understandable than others, but all of them add up to an empty chair across the desk and loss of income for that time slot.

CherriesJD/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Why do patients no-show?

The reasons are, obviously, widely variable among patients and circumstances. Some are more understandable than others, but all of them add up to an empty chair across the desk and loss of income for that time slot.

CherriesJD/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Why do patients no-show?

The reasons are, obviously, widely variable among patients and circumstances. Some are more understandable than others, but all of them add up to an empty chair across the desk and loss of income for that time slot.

CherriesJD/Thinkstock

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

ATLANTA – Everyone has to be on the same page when it comes to anorexia nervosa in a community hospital, according to pediatric hospitalists at Moses H. Cone Memorial Hospital in Greensboro, N.C.

M. Alexander Otto/MDedge News

Anorexia cases used to be rare there. When one came in, “everyone was anxious because we just didn’t know quite what to do,” said Suresh Nagappan, MD, a pediatrician and member of the teaching faculty at the hospital. Parents would hear one thing from one provider, something else from the next, and leave angry and confused. “Basically, it was a mess. We needed to standardize it,” he added.

So Dr. Nagappan and his colleagues created guidelines for treating patients with eating disorders about 3 years ago. “It was meeting after meeting for months, but well worth it,” he said at Pediatric Hospital Medicine.

Word of the hospital’s newfound expertise in anorexia has spread since then, and now it’s not unusual for Moses H. Cone to handle a few cases a week.

The pediatric hospitalist team has come to realize that, first and foremost, patients and families need to know why they are there; it’s about medical stabilization, not treating the eating disorder. That comes after discharge. Families need help sometimes to understand that it’s not a quick fix.

To make things clear, there’s strict criteria now for admission, based on American Academy of Pediatrics guidance. The main trigger is being under 75% of ideal body weight, but patients must also have systolic blood pressure below 90 mm Hg and other worrisome signs. “Sometimes, it feels like we’re splitting hairs” on who gets admitted, “but if we don’t have strict criteria on admission, we don’t have an end goal for discharge,” said pediatrician Maggie S. Hall, MD, also on the Moses H. Cone teaching faculty.

As for treatment, “food is medicine, and it’s not negotiable. We make that clear to everyone on day 1. If patients don’t eat their actual meal, they have 20 minutes to drink a supplement. If they can’t do that, they get a nasogastric tube,” Dr. Nagappan said. The tube is pulled after each meal, so that it remains an incentive to eat.

The team start patients with 1,600 calories a day and increase the intake by 200-250 calories a day. The goal is for a patient to gain 100-200 grams per day. Patients pick out what they want to eat with the help of a dietitian. When meals set off overwhelming anxiety, the Moses H. Cone team has learned that benzodiazepines can help.

Ironically, the initiation of regular meals is the most dangerous time for patients. As anorexic bodies switch from catabolic to anabolic metabolism, electrolytes can drop to dangerously low levels, causing arrhythmias, heart failure, and death. In general, “the reason these kids die is cardiac,” Dr. Nagappan said at the meeting, sponsored by the Society of Hospital Medicine, the AAP, and the Academic Pediatric Association.

Refeeding syndrome, as it’s known, is clinically significant in perhaps 6% of patients. The risk goes up if they are below 70% of their ideal body weight; have a prolonged QTc interval; or begin treatment with low phosphorous, magnesium, or potassium.

M. Alexander Otto/MDedge News

To counter the threat, electrolytes are measured twice a day at Moses H. Cone during the first week of treatment, and ECGs are taken daily for the first few days. “One thing to be really careful about is when you notice their heart rate beginning to creep up during rest. That can be a sign of developing cardiomyopathy; it’s an indication for us to get echocardiograms,” Dr. Hall said.

The Moses H. Cone team like to include families in meal times – it’s been shown to help – but family members need to be coached beforehand. They can’t be punitive. Mealtime talk has to be positive, and can’t focus on eating. Parents often need help handling their own anger and guilt before trying to eat with their child. Progress has to be monitored, but Dr. Nagappan cautioned that “you have to be really careful about how you get weights”; it should always be in the morning after the first void. Urine needs to be checked to make sure patients aren’t water loading.

Staff should be neutral about weight results, and keep them to themselves. Even something as benign as “good job” can be a problem. “You don’t want these patients focused on their weight. You want them focused on getting better and eating and taking it step by step,” he said.

The presenters had no disclosures to report.

[email protected]

ATLANTA – Everyone has to be on the same page when it comes to anorexia nervosa in a community hospital, according to pediatric hospitalists at Moses H. Cone Memorial Hospital in Greensboro, N.C.

M. Alexander Otto/MDedge News

Anorexia cases used to be rare there. When one came in, “everyone was anxious because we just didn’t know quite what to do,” said Suresh Nagappan, MD, a pediatrician and member of the teaching faculty at the hospital. Parents would hear one thing from one provider, something else from the next, and leave angry and confused. “Basically, it was a mess. We needed to standardize it,” he added.

So Dr. Nagappan and his colleagues created guidelines for treating patients with eating disorders about 3 years ago. “It was meeting after meeting for months, but well worth it,” he said at Pediatric Hospital Medicine.

Word of the hospital’s newfound expertise in anorexia has spread since then, and now it’s not unusual for Moses H. Cone to handle a few cases a week.

The pediatric hospitalist team has come to realize that, first and foremost, patients and families need to know why they are there; it’s about medical stabilization, not treating the eating disorder. That comes after discharge. Families need help sometimes to understand that it’s not a quick fix.

To make things clear, there’s strict criteria now for admission, based on American Academy of Pediatrics guidance. The main trigger is being under 75% of ideal body weight, but patients must also have systolic blood pressure below 90 mm Hg and other worrisome signs. “Sometimes, it feels like we’re splitting hairs” on who gets admitted, “but if we don’t have strict criteria on admission, we don’t have an end goal for discharge,” said pediatrician Maggie S. Hall, MD, also on the Moses H. Cone teaching faculty.

As for treatment, “food is medicine, and it’s not negotiable. We make that clear to everyone on day 1. If patients don’t eat their actual meal, they have 20 minutes to drink a supplement. If they can’t do that, they get a nasogastric tube,” Dr. Nagappan said. The tube is pulled after each meal, so that it remains an incentive to eat.

The team start patients with 1,600 calories a day and increase the intake by 200-250 calories a day. The goal is for a patient to gain 100-200 grams per day. Patients pick out what they want to eat with the help of a dietitian. When meals set off overwhelming anxiety, the Moses H. Cone team has learned that benzodiazepines can help.

Ironically, the initiation of regular meals is the most dangerous time for patients. As anorexic bodies switch from catabolic to anabolic metabolism, electrolytes can drop to dangerously low levels, causing arrhythmias, heart failure, and death. In general, “the reason these kids die is cardiac,” Dr. Nagappan said at the meeting, sponsored by the Society of Hospital Medicine, the AAP, and the Academic Pediatric Association.

Refeeding syndrome, as it’s known, is clinically significant in perhaps 6% of patients. The risk goes up if they are below 70% of their ideal body weight; have a prolonged QTc interval; or begin treatment with low phosphorous, magnesium, or potassium.

M. Alexander Otto/MDedge News

To counter the threat, electrolytes are measured twice a day at Moses H. Cone during the first week of treatment, and ECGs are taken daily for the first few days. “One thing to be really careful about is when you notice their heart rate beginning to creep up during rest. That can be a sign of developing cardiomyopathy; it’s an indication for us to get echocardiograms,” Dr. Hall said.

The Moses H. Cone team like to include families in meal times – it’s been shown to help – but family members need to be coached beforehand. They can’t be punitive. Mealtime talk has to be positive, and can’t focus on eating. Parents often need help handling their own anger and guilt before trying to eat with their child. Progress has to be monitored, but Dr. Nagappan cautioned that “you have to be really careful about how you get weights”; it should always be in the morning after the first void. Urine needs to be checked to make sure patients aren’t water loading.

Staff should be neutral about weight results, and keep them to themselves. Even something as benign as “good job” can be a problem. “You don’t want these patients focused on their weight. You want them focused on getting better and eating and taking it step by step,” he said.

The presenters had no disclosures to report.

[email protected]

ATLANTA – Everyone has to be on the same page when it comes to anorexia nervosa in a community hospital, according to pediatric hospitalists at Moses H. Cone Memorial Hospital in Greensboro, N.C.

M. Alexander Otto/MDedge News

Anorexia cases used to be rare there. When one came in, “everyone was anxious because we just didn’t know quite what to do,” said Suresh Nagappan, MD, a pediatrician and member of the teaching faculty at the hospital. Parents would hear one thing from one provider, something else from the next, and leave angry and confused. “Basically, it was a mess. We needed to standardize it,” he added.

So Dr. Nagappan and his colleagues created guidelines for treating patients with eating disorders about 3 years ago. “It was meeting after meeting for months, but well worth it,” he said at Pediatric Hospital Medicine.

Word of the hospital’s newfound expertise in anorexia has spread since then, and now it’s not unusual for Moses H. Cone to handle a few cases a week.

The pediatric hospitalist team has come to realize that, first and foremost, patients and families need to know why they are there; it’s about medical stabilization, not treating the eating disorder. That comes after discharge. Families need help sometimes to understand that it’s not a quick fix.

To make things clear, there’s strict criteria now for admission, based on American Academy of Pediatrics guidance. The main trigger is being under 75% of ideal body weight, but patients must also have systolic blood pressure below 90 mm Hg and other worrisome signs. “Sometimes, it feels like we’re splitting hairs” on who gets admitted, “but if we don’t have strict criteria on admission, we don’t have an end goal for discharge,” said pediatrician Maggie S. Hall, MD, also on the Moses H. Cone teaching faculty.

As for treatment, “food is medicine, and it’s not negotiable. We make that clear to everyone on day 1. If patients don’t eat their actual meal, they have 20 minutes to drink a supplement. If they can’t do that, they get a nasogastric tube,” Dr. Nagappan said. The tube is pulled after each meal, so that it remains an incentive to eat.

The team start patients with 1,600 calories a day and increase the intake by 200-250 calories a day. The goal is for a patient to gain 100-200 grams per day. Patients pick out what they want to eat with the help of a dietitian. When meals set off overwhelming anxiety, the Moses H. Cone team has learned that benzodiazepines can help.

Ironically, the initiation of regular meals is the most dangerous time for patients. As anorexic bodies switch from catabolic to anabolic metabolism, electrolytes can drop to dangerously low levels, causing arrhythmias, heart failure, and death. In general, “the reason these kids die is cardiac,” Dr. Nagappan said at the meeting, sponsored by the Society of Hospital Medicine, the AAP, and the Academic Pediatric Association.

Refeeding syndrome, as it’s known, is clinically significant in perhaps 6% of patients. The risk goes up if they are below 70% of their ideal body weight; have a prolonged QTc interval; or begin treatment with low phosphorous, magnesium, or potassium.

M. Alexander Otto/MDedge News

To counter the threat, electrolytes are measured twice a day at Moses H. Cone during the first week of treatment, and ECGs are taken daily for the first few days. “One thing to be really careful about is when you notice their heart rate beginning to creep up during rest. That can be a sign of developing cardiomyopathy; it’s an indication for us to get echocardiograms,” Dr. Hall said.

The Moses H. Cone team like to include families in meal times – it’s been shown to help – but family members need to be coached beforehand. They can’t be punitive. Mealtime talk has to be positive, and can’t focus on eating. Parents often need help handling their own anger and guilt before trying to eat with their child. Progress has to be monitored, but Dr. Nagappan cautioned that “you have to be really careful about how you get weights”; it should always be in the morning after the first void. Urine needs to be checked to make sure patients aren’t water loading.

Staff should be neutral about weight results, and keep them to themselves. Even something as benign as “good job” can be a problem. “You don’t want these patients focused on their weight. You want them focused on getting better and eating and taking it step by step,” he said.

The presenters had no disclosures to report.

[email protected]