OUCH!!! My Toe is Killing Me

4% of Americans at some point in their lives will be diagnosed with gout (over 8 million people). This prevalence is increasing in developed countries over the last decade, exacerbated by increasing rates of co-morbidities that mediate elevated uric acid levels including obesity, metabolic syndrome, alcohol intake, use of diuretics, diets high in proteins such as meat, chronic kidney disease and hypertension.

Acute gout is characterized by joint swelling and pain. In some individuals, these acute attacks increase in frequency and severity leading to chronic gout. Chronic, intermittent gout, affects quality of life, and metabolic function including cardiac function.

Managing Acute Gout

The American College of Physicians released a new guideline on managing acute, recurrent gout[1] which provides recommendations for both non-pharmacologic and pharmacologic strategies for improved management and avoidance of chronic gout. These guidelines released in January 2017 re-examined evidence relating to specific therapeutic interventions, and concluded four major recommendations for the management of acute gouty attacks.

#1: Acute attacks should be managed by NSAIDS, steroids, or colchicine. One placebo controlled trial demonstrated that NSAIDs were superior in managing pain but provided no additional benefit in reducing swelling. There are no placebo controlled trials of oral steroids but six randomized controlled trials demonstrated similar pain outcomes with NSAIDS. There have been five randomized controlled trials of colchicine that have all demonstrated that it reduces pain in acute gout. Moderate quality evidence suggests that low dose colchicine (1.2mg followed by 0.6 mg after 1 hour) are as effective as higher dose regimens with fewer gastrointestinal side effects.

#2: When using colchicine in managing acute gout, the recommendation is to use the low dose regimen as described above.

#3: Urate lowering therapy should not be used following first episode or in patients who have infrequent episodes (<= 2 per year). For patients with more severe episodes, recurrent attacks (>=2 per year), and tophi, chronic renal disease or uric acid renal stones), shared decision making is warranted. Continuation of colchicine or NSAIDs are useful for up to 8 weeks after the acute flare. There is no compelling evidence that monitoring uric acid levels is useful, although levels of 6.8 mg/dl are often used as a trigger for initiating urate lowering therapy.

#4: Shared decision making between clinician and patient should occur to discuss benefits, harms, costs and preferences before initiating urate lowering therapy including concomitant prophylaxis in patients with recurrent gout.

The 2012 American College of Rheumatology guidelines for prophylaxis support the use of colchicine (low dose) or NSAIDS as first line prophylaxis, with low dose steroids as second line. These guidelines recommend starting prophylaxis prior to or at the time of starting urate lowering therapy.  Prophylaxis should be continued for at least 8 weeks though regimens longer than 12 months have not been studied in randomized trials and there is no evidence of optimal duration of urate lowering therapy. It should be noted that in several studies when prophylaxis was discontinued after 8 weeks, rates of acute flares doubled, and that when continued for at least six months resulted in a significant decline in acute flares.

[1] http://annals.org/aim/article/2578528/management-acute-recurrent-gout-clinical-practice-guideline-from-american-college

My Baby is Hot

CASE: You are working after hours and a young mother brings her 12 month old infant with fever 104 C

Should you admit this patient and perform an infectious workup or send the patient home with close surveillance?

In any given year, 15% of visits to the ED or urgent care by children under 15 years of age are children with fever. The vast majority of these children have self-limited viral infections. Yet serious illness is also manifested by fever in children and includes meningitis, sepsis, and pneumonia. With increasing rates of vaccination against hemophilus and pneumococcus, invasive infection and meningitis have been declining. The most common serious infections are pneumonia in the less than three month group of infants and urinary tract infection in infants older than 3 months. Red flags indicating serious illness include any of the following:

  • Change in sensorium
  • Changes in crying/moaning patterns
  • Cyanosis
  • Rapid breathing and shortness of breath
  • Hypotension
  • Signs of meningeal irritation
  • Rashes esp petechial
  • seizures

This past year, the American College of Emergency Physicians[1] have released an updated clinical policy on evaluation of the child under two years with fever. Their recommendations are summarized below:

Infants 1-3 months: consider lumbar puncture (LP) to rule out meningitis in infants 29-90 days and admitted to hospital for observation. Antibiotics are appropriate after LP until cultures are returned as negative

Children 2 months – 2 years: perform a chest radiograph in children with fever of at least 100.4F with no clear infection source but have cough, rales or hypoxia. Do not perform CXR in children with fever and wheezing and high probability of bronchiolitis. Consider performing urinalysis and urine culture especially in high risk children including girls under 1 year, uncircumcised boys, fevers lasting longer than 24 hrs. and no clear infection source. If there is a positive urinalysis (leukocyte esterase or nitrates) start antibiotics without waiting on results of urine culture. AAP recommends collecting urine samples through cauterization or suprapubic aspirate.

If the infant or child presents during the influenza season, consider performing rapid influenza testing.

If serious infection is strongly considered, the following age grouped antibiotics are recommended:

Under 1 month                                                 Ampicillin + gentamicin or cefotaxime

Over 1 month with urinary:                         cefotaxime or cefixime

1-3 months possible meningitis                 ceftriaxone

1-3 months (listeria/enterococcus)          add ampicillin

3 months + pneumonia                                 amoxicillin or azithromycin

[1] Annals of Emergency Medicine, May 2016; 67(5): 625-639

Is This COPD?

CASE: Mr Dooby, a 52 year old male,  presents to your office with a chronic cough and shortness of breath with normal activities, worsening over the last 12 months. By history, he has been a pack per day smoker since he was 18 years of age.

Does this patient have chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease characterized by chronic cough, shortness of breath with exertion or at rest. It is the 3rd leading cause of death in the United States affecting 4-9% of the population with up to 90% of COPD cases related to smoking.  Diminished breath sounds, peak flow rates of under 350-l/min and a 30 pack year smoking history are 98% positively predictive. Diagnosis can be confirmed by spirometry with bronchodilators with an FEV1/FVC ratio of under 0.7 with increasing degrees of irreversibility (by bronchodilator). The GOLD classification is based on this latter index with the FEV1 % of predicted

> 80        mild

50-79     moderate

30-49     severe

< 30        very severe

 

The primary differential is with asthma which is characterized by reversibility and variability of airflow obstruction. Other conditions to consider include congestive heart failure, lung cancer, pulmonary arterial hypertension, interstitial lung disease and upper airway/ vocal cord dysfunctions.

The foundations of management include smoking cessation through tobacco cessation programs and pharmacotherapy with nicotine replacement, varnenicline, or buproprion. Also includes regular use of inhaled bronchodilators starting with short acting beta agonists or anticholinergics for mild COPD with addition of long acting beta agonist (LABA) or long acting anticholingerics. With progression of disease severity, additional of an inhaled corticosteroid in combination with a LABA is indicated.  Roflumilast (Daliresp) which is a phosphodiesterase-4 inhibitor should also be considered in severe or very severe COPD.

The role of oxygen has evolved with recommendations now to provide supplemental oxygen to patients with COPD who have severe resting hypoxia (O2 sat 88% or less). The key is to ensure that patients use oxygen for at least 15 hours per day to achieve target O2 saturations of 88-92%. Pulmonary rehab is also important for severe-very severe COPD patients. Mucolytics and anti-tussives are NOT recommended and provide little benefit.

As the disease progresses, consider providing or referring for palliative care. Use of the BODE Index allows you to determine the risk of dying in your COPD patients. BODE includes four variables: FEV1, six minute walk distance, MRC dyspnea score, and BMI. Scores indicate four year survival rates with 0-2 = 80% survival up to 7-10 18% survival.

Grandma is Acting Out

CASE:  Your patient brings in her grandmother (82 yrs old diagnosis with dementia) with complaints that she is up all night screaming incoherently, strikes out at caregivers, and angers easily.

What can you offer your patient to better manage her mother’s agitation?

Dementia patients commonly have behavioral and psychological symptoms that present in several clusters that include psychosis (delusions, hallucinations) and agitation/aggression, and disinhibition (agitated behaviors) Agitation and psychotic symptoms in demented patients is common, occurring in up to 30% of patients and may increase with disease progression. Dementia patients with agitation and other neuropsychiatric disorders cause significant stress on the caregivers, lead to excess hospitalizations and nursing home admissions, and carry higher mortality.  Environmental and non-pharmacologic interventions are the mainstay of treatment. These include reducing ambient noise and clutter, establishing schedules of activities, periodic orientation. It is important to stay alert to possible sources of pain that the patient may be experiencing but unable to express, and manage these as appropriate. Of note 36% of patients with agitated dementia have an underlying undetected illness.

In evaluating patients with dementia presenting with agitation or other behavioral problems, consider the three main factors that contribute:

Patient-related: acute medical illness, underlying psychiatric illness, sensory deficits

Care-giver related: poor communication, emotional instability

Environmental factors: clutter, overstimulation, understimulation

Pharmacologic therapies should be reserved for severe conditions that are not well managed just by non pharmacologic therapies alone. Note that the FDA has NOT approved any medication for the management of behavioral conditions related to dementia so all of the medications discussed below are used in an off label manner.

Anti-psychotics. The atypical anti-psychotics, risperidone and aripiprazole, have been shown in 15 randomized controlled trials to be modestly effective at managing behavioral symptoms. Oddly, presence of psychosis was associated with less clinical effectiveness for agitation than in patients without psychosis. The atypical anti-psychotics are not without their adverse effects. Based on re-analysis of 17 RCTs in 2005, the FDA issued a black box warning that indicated a 1.7 fold increase in mortality risk in patients treated with these drugs. Beyond excess mortality, this class of drugs was also associated with extrapyramidal effects, hyperprolactinemia, prolonged QT syndrome (thought to be the source of excess mortality) and greater anti-cholinergic side effects. Conventional antipsychotics such as haloperidol also carry a similar black box warning.

Benzodiazepines.  Curiously, there are no RCTs on clinical effectiveness of this class of drug in the management of agitated dementia, and are NOT recommended in the management of behavioral issues in dementia with the exception of acute crisis. Of particular concern with the use of benzodiazepines is the increased risk of dependency and worsening of dementia as well as excess falls.

Take home lessons are:

  1. evaluate the three categories of factors and address each
  2. Preference is for non pharmacologic strategies (environment, caregiver)
  3. use atypical anti-psychotics if behavior is severe and not managed well by non pharmacologic interventions
  4. Be cautious. Avoid benzodiazepines.

What to Know but Not Forget About Dementia

CASE: One of your patients brings in her mother who she reports is having increasing forgetfulness. She is 82 years old, with longstanding hypertension and heart disease. No history of stroke. The forgetfulness was starting to be noticed in her late 60’s and has progressed gradually since then.

Does this patient have dementia? The Alzheimer’s Association recommends looking for the ten warning signs of dementia that include:

  • Memory loss that affects daily living or work
  • Difficulty performing familiar tasks
  • Problems with language
  • Disorientation in time and space
  • Poor or decreased judgement
  • Problems with abstract thinking
  • Misplacing things
  • Changes in mood or behavior
  • Changes in personality
  • Loss of initiative

Dementia is very common, affecting up to 50% in patients over 85 years of age, and 10% in patients 65 years. As we all age, our memories decline. However, primary care physicians should be alert to patients who are experiencing memory loss without other signs of cognitive impairment.  This is defined as mild cognitive impairment (MCI). Unfortunately up to 81% of patients who meet the criteria for dementia never receive a documented diagnosis. Up to 25% of patients with MCI progress to full dementia each year, and should be evaluated and managed.

Key diagnostic studies include a CBC, serum glucose, serum electrolytes with BUN and creatinine, serum B12 levels, liver function tests, thyroid screening with TSH and depression screening. The latter is crucial as many patients with depression present with mild cognitive impairment. At the present time, there is little evidence to screen for syphilis (unless specific risk factors exist), doing EEGs, APOE genotyping, MR or CT scans or SPECT scanning. Use of PET scans or genetic screening for Tau mutations are controversial.

If cognitive impairment exists, consider use of cholinesterase inhibitors or vitamin E in patients with mild to moderate dementia. Diagnose and treat depression and psychosis as appropriate. Many patients with dementia develop functional or behavioral problems. Consider the following:

  • Behavioral modifications (scheduled toileting)
  • Music especially during meals and bathing
  • Walking or light exercise
  • Pet therapy (yes with animals, not electrons)
  • Cognitive exercise

Advance Care Planning Series – #3 Advance Directives and POLST

Completion of the Advanced Directive: When a healthcare agent or surrogate is named and a living will is completed designating what the patient’s wishes might be, the Advanced Directive is signed by the patient. In order for the Advanced Directive to become a legal document, it must either be witnessed by two people or notarized by an authorized public notary. Note that both the witness signature and the notarization only testify that the signature belongs to the patient, and not to the validity or completeness of the Advanced Directive. As noted above, the patient can elect to activate the Advanced Directive immediately upon signature and witness/notarization or can elect to activate after signature and witness/ notarization only when the patient is incapacitated.

When to Consider a Physician Order for Life Sustaining Treatment (POLST): The Advanced Directive is appropriate when a serious illness or chronic disease is first diagnosed at minimum, and updated on a regular basis as the patient ages and their health status changes. A good case could be made for starting to do Advance Care Planning, having advance directive conversations, when the patient is young. One could consider for instance, a high school graduate to receive a diploma and an advance care planning document. What is key is the recognition that advance care planning is about repeated conversation over time with an individual about their wishes. The Advanced Directive is the document that captures these conversations.

When a patient becomes more seriously ill and is approaching the last phases of a terminal trajectory, you could discuss physician orders for life sustaining treatment and complete a POLST form (capolst.org). This state approved form has four sections:

Section A: cardiopulmonary resuscitation (CPR or Do Not Attempt Resuscitation = allow natural death)

Section B: medical interventions (full, selective, comfort-focused)

Section C: artificial nutrition (long term, trial, no artificial means including feeding tubes)

Section D: Information and signatures.

This form can be signed by either a physician or a nurse practitioner/ physician’s assistant. Make copies for the patient’s medical record, provide copy to the patient and the patient caregiver/surrogate. This form should be with the patient at all times.

To learn more about POLST, the link below sponsored by the California Coaltion for Compassionate Care provides great resources.

http://capolst.org/

http://polst.org/

Partnership HealthPlan Commitment:  Our commitment to the seriously ill members in our plan is strong and manifest through the Partnership HealthPlan’s Offering and Honoring Choices Initiative. This is a set of 14 activities that promote, support and facilitate a spectrum of palliative care activities, including completion of advance care directives and POLST completion. Of note, PHC has included advance care planning in the Quality Incentive Program (QIP) which includes $100 per member for attestation of an advance care plan conversation and an additional $100 for submission of a completed POLST.

Other Resources

http://coalitionccc.org/tools-resources/advance-care-planning-resources/