1. Acknowledge the unique demands of a rural practice including:

2. number of hours worked per week in patient care.

3. number of patients seen per week.
4. the difficult patient population.
5. physician isolation.
6. limited resources to access for back-up.
7. home visits.
8. nursing home care.
9. on-call demands.
10. “24 hr” accessibility.

11. the demands on yourself and family.

12. Acknowledge some of the critical issues that rural physicians in practice face with regards to the delivery of health care in a remote community which include:

13. shortage of health care professionals, especially the lack of available consultants in other specialty fields.

14. reimbursement differential for services.
15. financial pressures that can threaten small hospital closure, which in turn affect your mode of practice and your referral pattern.
16. geographical distance to referral center which in turn alters your mode of practice.
17. staffing shortages that alters your mode of practice.
18. facility limitations that affects your pattern of referral.

19. administrative and leadership expectations (e.g. medical director of local nursing home, hospital committee membership, school board, etc.).

20. Understand the important role that time management plays in the rural physician’s ability to balance practice and a normal lifestyle.

21. Understand the importance of establishing good working relationships with other medical colleagues in the same community and with those in outlying areas (referral centers).

22. Understand the benefits of utilizing other community resources in the delivery of health care to the rural population, e.g. public health agencies, home health care, hospice, etc.

23. Acknowledge the many roles that a rural physician inherently accepts in their respective community outside the realms of being a physician, e.g. community leader, hospital advocate, counselor, personal friend, school board member, etc.

24. Understand the importance of identifying their own personal and social needs as a physician living in a remote community.

Goals

1. To familiarize residents with the problem of depression and its management in primary care.
2. To provide the resident a practical experience in the management of patients suffering depression.

Objectives

1. The resident will be able to recognize the common signs and symptoms of depression.
2. The resident will understand the therapeutic approaches to the management of depression.
3. The resident will be knowledgeable about the medications used for the treatment of depression and how to augment pharmacological treatment.
4. The resident will know how to evaluate risks to patients and others.
5. The resident will be familiar with a variety of web-based resources concerning depression.
6. The resident will be familiar with the EPIC smart text for depression.

Methods

1. The resident will read the following required web-based resources:

   • Webb MR, Dietrich AJ, Katon W, Schwenk TL. Diagnosis and Management of Depression. American Family Physician Monograph No. 2, 2000. http://www.aafp.org/afp/monograph/200002/index.html

   • American Board of Family Practice Practice Guideline: Depression http://www.familypractice.com

   • Under “Practice Management Center,” click on “ABFP Guides” Under “ABFP Guides” click on “Reference Guides” then “Depression” Review specifically the information on special populations: Children and the Elderly

   • Cadieux, RJ. Practical management of treatment-resistant depression. American Family Physician. December, 1998. http://www.aafp.org/afp/981200ap/cadieux.html

   • Gliatto MF, Rai AK. Evaluation and treatment of patients with suicidal ideation. American Family Physician. 1999;59:1500-06. http://www.aafp.org/afp/990315ap/1500.html

2. The resident will see clinic patients suffering from depression and apply the information gleaned above to their clinical care, using the EPIC smart text.

Evaluation & Post-test

1. The resident will precept all patients seen in the module clinic with the TFM preceptor of the day.
2. The resident will complete the electronic post-test for the module found on the curriculum website.
3. The resident will complete the electronic evaluation for the learning module found on the curriculum website.

Additional Curricular Resources

The resident will access and become familiar with the contents of the following websites to facilitate further study or for patient education:

For practitioners: Depression Management Tool Kit The MacArthur Initiative on Depression & Primary Care at Dartmouth & Duke http://www.depression-primarycare.org

Click on “Tool Kit” under Resources for Physicians

Practice Guideline for the Treatment of Patients with Major Depression American Psychiatric Association http://www.psych.org/clinres/pracguide.cfm

Select guideline for Major Depressive Disorder

University of Washington Health Sciences Library PrimeAnswers: Best Evidence at the Point of Care http://www.primeanswers.org/primeanswers/

Click on “Common Conditions” tab at top and then “Depression” tab to link to topics

1. A patient with depression is least likely to have which of the following symptoms?A) Loss of interest or pleasure in activities B) Abdominal Pain C) Insomnia D) Fatigue E) Significant weight loss
2. Which of the following are the most effective forms of psychotherapy for patients with mood disorders?A) Cognitive behavioral therapy and interpersonal therapy B) Psychoanalysis C) Long-term supportive therapy D) Behavioral therapy alone
3. The AFP monograph recommends using the BATHE technique as an effective counseling technique. Which of the following is not included in the BATHE technique?A) Assessing function (handling) B) Identifying the patient’s associated “feeling state” (affect). C) Identifying behavior changes the patient can make to reduce stress (behavior). D) Legitimizing the patient’s feelings (empathy). E) Identifying the associated conflict or struggle (trouble).
4. You have prescribed a selective serotonin reuptake inhibitor (SSRI) to a patient but do not note any difference in symptoms in the next 6 weeks. You should:A) Double the dose B) Keep the patient on the same medication for an additional 6 weeks C) Prescribe a different SSRI D) Add an antidepressant from a different therapeutic class E) Refer the patient to a psychiatrist
5. You prescribe an antidepressant to a patient who has experienced her first episode of major depression. She has an excellent clinical response and after 3 months, you determine that there has been a full clinical recovery. You should:A) Discontinue the medication immediately B) Taper the medication over the next month C) Continue the medication indefinitely D) Continue the medication for at least 6 more months E) Refer the patient to a psychiatrist
6. You prefer to prescribe an antidepressant with the lowest postential for toxicity from an overdose. You should select:A) Tricyclic antidepressants B) Monoamine oxidase inhibitors C) Selective serotonin reuptake inhibitors D) None of the above
7. You are treating a patient for depression. He expresses great concern about the potential for weight gain with the medication. Which of the following antidepressants is least likely to cause weight gain?A) Paroxetine B) Mirtazapine C) Bupropion D) Venlafaxine E) Amitriptyline
8. You believe a depressed patient would benefit from some sedation. Which of the following antidepressants is the most sedating?A) Trazodone B) Clomipramine C) Fluoxetine D) Bupropion E) Nefazodone
9. You are concerned that your depressed patient might be at risk for suicide. Which of the following behaviors is not a warning sign of suicidal tendencies?A) Pacing, agitated behavior, frequent mood changes and chronic episodes of sleeplessness B) Actions or threats of assault, physical harm or violence C) Delusions or hallucinations D) Crying and socially isolating E) Unusually risky behavior
10. Which of the following is not recommended to aid physicians in assisting potentially suicidal patients:A) Being attentive and listening to the patient B) Remaining calm and not appearing threatened C) Confronting the patient with the foolishness of their behavior D) Discussing suicide in a calm, reasoned manner E) Emphasizing that suicide causes a great deal of pain to family members

Purpose: The purpose of the Family Practice Service rotation is to assist residents to become more familiar with the role of functioning of a family physician, and to increase their knowledge regarding the management of common ambulatory problems.

Structure: Focused Clinics are special clinics that exist in addition to the normal continuity clinics that the residents are required to attend. These clinics are “focused” in the sense that patients who are appointed for these clinics are pre-screened to have one of the top 10 presenting problems in ambulatory care (see below).

Only 3 patients are appointed per clinic to allow the resident ample time to obtain precepting, read around a problem/presentation, and provide patient care. The intent is for the residents to become well versed in the diagnosis, epidemiology, treatment, and prognosis of a number of common ailments that will be presented to them as ambulatory practitioners.

Precepting: The preceptor for the resident in the focused clinics will be the regularly assigned preceptor for the half day. Precepting for the focused clinics is NOT the same as for 1:1 precepting, which occurs outside of the rotation.

Presenting Complaints To Be Appointed For Focused Clinics:

First Year Residents

• Hypertension
• Diabetes
• Depression
• Anxiety

Second & Third Year Residents

• CAD
• CHF
• Atrial fibrillation
• Low back pain
• Somatization
• Obesity

1. By definition, Somatization Disorder has an onset after age 30.True False

2. Properly recognized and treated patients with Somatoform Disorders usually have a complete recovery.True False

3. The specifically described Somatoform Disorders are readily identified discrete entities, not a spectrum of illness.True False

4. Cognitive Behavioral Therapy has been demonstrated to improve physical symptoms and functional status.True False

5. It is important to “name the disease” to help the somatizing patient to accept it.True False

6. Somatization disorder symptoms are often amplified by stressful events.True False

7. The more physicians that participate in the patient’s care, the better off they will be.True False

8. Patients should be encouraged to do their own problem solving.True False

9. The physician should not be too empathetic, because the somatization patient is not really suffering much.True False

10. Patients should be discouraged from coming in regularly, but should learn to cope at home, and only come in prn increased symptoms.True False

Introduction:

Somatization is very common in family practice. Patients with physical complaints with no readily identifiable/treatable cause can be very time consuming and frustrating to work with. These patients are often labeled as “problem patients.” It is important to develop an understanding of which patients may have characteristics of Somatoform Disorders and to have an approach to evaluation and appropriate management of those patients. There is a spectrum of somatization, with many patients having a “subsyndromal” form and not meeting the full criteria of a specific disorder.

Definitions:

Somatization: is the tendency to experience and report bodily symptoms that have no physiologic explanation, to misattribute symptoms to disease, and to seek medical attention for them.

In many patients Somatization becomes a form of chronic illness behavior.

In the most severe cases Somatization becomes the focus of the patient’s life, and the sick role becomes the patient’s predominant mode of relating to the world.

The symptoms are not intentional, or for secondary gain

Somatoform Disorders (DSM-IV-TR criteria) Somatization Disorder (300.81):

History of many physical complaints beginning before age 30 years, that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.

Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:

Four pain symptoms: a history of pain related to at least four different sites or functions (e.g. head, abdomen back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse,or during urination).

Two gastrointestinal symptoms: a history of a least two gastrointestinal symptoms other than pain (e.g. nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods.

One sexual symptom.

One pseudoneurological symptom:

C. Either 1) or 2)

After appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a know general medical condition or the direct effects of a substance, or….

When there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings

D. The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering)

Undifferentiated Somatoform Disorder (300.82)

One or more physical complaints (e.g. fatigue, loss of appetite, GI or GU complaints)

Either 1 or 2 as above

Symptoms cause clinically significant distress

Duration at least 6 months

Not intentionally produced

Pain Disorder (307.80 and 307.89)Acute <6 months, Chronic > 6 months

Pain in one or more anatomical sites is the predominant focus

Pain causes clinically significant impairment

Psychological factors play an important role in the onset and severity

Hypochondriasis (300.7) 21-38% of patients also have somatization disorder)

Preoccupation with fears of having a serious disease based on the person’s misinterpretation of bodily symptoms.

Preoccupation persists despite appropriate medical evaluation and reassurance.

The belief in A. is not of delusional intensity

The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

The duration is at least 6 months

Specify “with poor insights” if for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable.

Related Disorders-but are intentional: Factitious Disorders(300.16 and 300.19): with predominantly Physical Signs and symptoms 300.19.

With combined psychological and Physical signs and symptoms

Intentional production or feigning of physical or psychological signs or symptoms

Motivation for the behavior is to assume the sick role

External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent.

Tends to occur in patients who have some medical knowledge.

Malingering (V65.2) The essential feature of Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.

Suspect if:

Medicolegal context of presentation

Marked discrepancy between the person’s claimed stress or disability and the objective findings

Lack or cooperation during the diagnostic evaluation and in complying with the prescribed treatment regiment.

The absence of Antisocial Personality Disorder

Incidence:

38% of primary care patients complain of symptoms that have no serious medical basis.

46% of new symptoms contain some element of Somatization.

6% of Primary Care patients have Somatization Disorder (similar to DM or UTI).

Course of Illness: Unknown etiology 83-100% of patients have comorbid conditions, often psychiatric disorders.

General: Physical symptoms may offer a language to express distress when patients do not easily express emotions in words (alexithymia), i.e. the “sick role” gives relief. These are generally chronic, relapsing conditions, not curable but readily manageable. Symptoms may offer benefits of social support, disability payments, escape from obligations and or a compromise for internal conflicts.

Initial Approach: Early recognition and structured management will help improve patient care, decrease physician frustration, and improve overall practice function. Inform the patient up front that this will be your “get acquainted” visit to collect information to be able to do a competent evaluation, and that you may not have “all the answers” at the end of the visit.

History: Chief Complaint:

Very specifically note onset, duration, previous and current functional status, rate pain on 0-10/10 scale.

Employment status:

Working prior to onset of symptom? On the job injury? Did the patient like their job?

Any outstanding lawsuits, disability claims?

Social History:

Screen for depression(60%), anxiety (86% of Hypochondriasis patients disorder, 60% have OCD and Panic Disorder)), PTSD

Personal History of Mental Illness?

Family of origin history:

History of impairment or dysfunction caused by physical ailments among family members whom the patient witnessed during childhood

Childhood Abuse

Sexual Abuse

Habits: Tobacco, Etoh, prescription drug abuse, illicit drug use current or remote

Previous Medical Evaluation for this or related issues: Specific names and dates, obtain release of records for these reports.

Physical:

Perform a thorough focused exam of the related area.

Labs/Imaging:

Do conservative diagnostic workups: investigate objective findings, not subjective complaints. Beware of false (+). Do not repeat lab/images done elsewhere.

Therapy:

“The gold standard in the treatment of patients with multiple, unexplained physical symptoms is a long-term empathetic relationship with a primary care physician.”

The goals of treatment are:

Care for the patient, not necessarily “cure” the somatization

Rule out concurrent physical disorders.

Maintain or improve the patient’s overall functioning.

Do not treat what the patient does not have.

Obtain old medical records.

Actively identify and address psychosocial factors, mental illness, and substance abuse.

Encourage patients to develop problem-solving skills.

Several studies have found that cost-effective treatment requires:

The Family Physician is the patient’s primary, and if possible, only physician.

Scheduling regular outpatient visits every 4-6 weeks.

May need to be q 2 weeks initially if severely decompensated.

Making these frequent visits brief enough (e.g. 15 minutes) to fit into a busy clinic’s schedule.

Conducting a partial physical exam of the organ system that is the object of the patient’s complaints during each visit.

Follow-Up Appointments:

History: Interval changes in symptoms

Specifically functional status

Adherence to recommended treatments

Review of old records and consultations when available

Physical Exam:

Focused on areas of concern at each visit

Lab/Imaging Studies:

Review results available

Assessment:

Working diagnosis for medical problem

Carefully identify comorbidities E.g. Mental Illness, substance abuse, secondary gain

Plan:

Continue to acknowledge the patient’s suffering and disability.

Provide the patient a name for the illness.

Recommend/negotiate an approach to improve functional status, e.g. aerobic activity, Cognitive Behavioral Therapy.

Specifically address treatment of comorbidities.

Don’t forget to address age/gender appropriate Health Maintenance needs.

Agree to schedule of frequency of regularly scheduled follow-up appointments to address needs (e.g. q 4-6 weeks), not prn.

References: American Family Physician review article February 15 and March 1, 2000 http://www.aafp.org/afp/20000215/1073.html

http://www.aafp.org/afp/20000301/1423.html

DSM-IV-TR, American Psychiatric Association, 2000

Initial Evaluation (or new patient to you/practice)

Chronic Heart Failure Epic Smart Text

I. History

.name is a .age male/female presenting today for: Establishing care for known CHF / Follow up of known CHF / Possible signs and symptoms of CHF / * (If previous known dx, details of eval, hospitalization and treatment): *

Current relevant ROS: (class 1 rec by ACC/AHA) General: fatigue, decreased concentration or memory, insomnia Cardiopul: chest pain, SOB, DOE, orthopnea, PND, edema GU: oliguria, nocturia GI: Abdominal distension, N/V

PMH: Risk factors for underlying causes: Htn, CAD/angina, MI, DM, congenital/valvular dz Other CV risk factors: lipids, CVA, PVD Risk factors for precipitating causes: Anemia, thyroid dz, renal dz, COPD, Renal dz.

PSH: cardiac surgeries, catheterization, angioplasty

FH: CV dz, sudden death, early death CV event

Medications (including all otc, herbals, etc)

Habits: tobacco, etoh, illicit drugs Lifestyle: diet - sodium, fats, salt Level usual activity, exercise

II. Physical Exam

General: .vs. Neck: presence of JVD, abdominojugular reflex, thryomegaly, carotid bruits Cor: gallops, murmurs, rubs Lungs: presence of rales, wheezes, rubs Abd: hepatomegaly, ascites Ext: pedal edema, pulses, warm/cool to touch

III. Lab / Imaging

Class 1 recommendations per AHA / ACC - should have baseline: Cbc, UA, chem. 18 (lytes, BUN/Scr, LFT’s), TSH (if unexplained, ferritin, ANA) ECG CXR Echo (if unexplained - consider stress echo, stress imaging, if hx angina, cath vs stress imaging)

IV. Assessment

Type: diastolic vs systolic AHA class: (A,B,C,D) NYHA fx class (1,2,3,4) Compensated vs uncompensated

V. Management

1. Non pharmacologic Diet: sodium restriction. (Calorie restriction/wt loss if overwt) Habit/Lifestyle modifications Tobacco cessation, modest etoh, no illicit drug use Activity recommendations

2. Pharmacologic - Systolic dysfx ACEI - (class 1 rec ACC/AHA for all w/ hx of systolic dysfx, or prev MI) Diuretic (class 1 rec if hx/evidence fluid overload) Betablocker (class 1 rec if prev MI, hx LV dysfx but no current fluid retention)

Digoxin (class 1 rec for stage C symptomatic HF pts) Nitrates -(class IIb rec- if pulmonary venous congestion/already on ACE,BB,dig,diuretic) Spironolactone - (class IIa for NYHA class IV pts, already on ACE,BB,dig,diuretic) Hydralazine/Nit combo - same as spironolactone for pts not tolerant of ACEI or ARB

Diastolic dysfx Diuretics (class 1 rec ACC/AHA - tx pul/peripheral edema) After that: BB, CCB, ACE to minimize sx’s and tx Htn

1. Other pharmacologic recs: Treat Htn to current JNC VII recs, using ACEI, BB, diuretics as initial drugs of choice Treat lipid disorders to current recs ASA qd if underlying CAD (class IIa rec) Anticoagulation if chronic Afib (class 1 rec)

2. Pt education Review basics of dx, dz process, rx and tx goals, when to call w/ probs, watching home wts Follow up in *

.me

Follow up Evaluation of Chronic Heart Failure Epic Smart Text

I. History .name is a .age male/female presenting today for: Follow up of known CHF

Updates on evaluations, hospitalization or treatment since last visit: none/*

Current relevant ROS: (class 1 rec by ACC/AHA) General: fatigue, decreased concentration or memory, insomnia Cardiopul: chest pain, SOB, DOE, orthopnea, PND, edema GU: oliguria, nocturia GI: Abdominal distension, N/V

Medications: update list, including all otc, herbals, etc Compliance with prescribed regimen: good / < ideal *

Habits: tobacco, etoh, illicit drugs Lifestyle: diet - sodium, fats, salt Level usual activity, exercise

II. Physical Exam

General: .vs. Neck: presence of JVD, abdominojugular reflex, thryomegaly, carotid bruits Cor: gallops, murmurs, rubs Lungs: presence of rales, wheezes, rubs Abd: hepatomegaly, ascites Ext: pedal edema, pulses, warm/cool to touch

III. Lab

if on diuretics/ ACE - q 6 month chem. 7 if on digoxin, q 6 - 12 mo dig level

IV. Assessment

Type: diastolic vs systolic AHA class: (A,B,C,D) NYHA fx class (1,2,3,4) Compensated vs uncompensated

V. Management

1. Non pharmacologic - review Diet: sodium restriction. (Calorie restriction/wt loss if overwt) Habit/Lifestyle modifications Tobacco cessation, modest etoh, no illicit drug use Activity recommendations

2. Pharmacologic - Systolic dysfx ACEI - (class 1 rec ACC/AHA for all w/ hx of systolic dysfx, or prev MI) Diuretic (class 1 rec if hx/evidence fluid overload) Betablocker (class 1 rec if prev MI, hx LV dysfx but no current fluid retention)

Digoxin (class 1 rec for stage C symptomatic HF pts) Nitrates -(class IIb rec- if pulmonary venous congestion/already on ACE,BB,dig,diuretic) Spironolactone - (class IIa for NYHA class IV pts, already on ACE,BB,dig,diuretic) Hydralazine/Nit combo - same as spironolactone for pts not tolerant of ACEI or ARB

Diastolic dysfx Diuretics (class 1 rec ACC/AHA - tx pul/peripheral edema) After that: BB, CCB, ACE to minimize sx’s and tx Htn

1. Other pharmacologic recs: Treat Htn to current JNC VII recs, using ACEI, BB, diuretics as initial drugs of choice Treat lipid disorders to current recs ASA qd if underlying CAD (class IIa rec) Anticoagulation if chronic Afib (class 1 rec)

2. Pt Ed Review compliance issues, tx goals Follow up in *

.me

1. On the initial visit for hypertention, the physician should review for history, signs and symptoms of possible secondary hypertension. Findings suspicious for possible secondary hypertension would be: A) A BMI > 40, a neck circumference > 43 cm, snoring and daytime somulence B) A history of chronic nephritis and hematuria C) Binge alcohol drinking and taking diet and herbal supplements D) An abdominal bruit E) All of the above

2. An individual with a Blood Pressure of 125/84 would be counseled: A) They have normal blood presure B) They have pre-hypertension and should make lifestyle changes C) They need medication

3. An inpatient with a new stroke 2 days ago develops a blood pressure of 180/110, a pulse of 60, a stable neurologic exam and no symptoms. Appropriate BP treatment would be: A) Lower immediately with Nifedipine 20 mg, break capsulre and give sublingual B) Lower with labatelol 20 mg IV over 2 minutes, then a drip at 2 mg/min to titrate BP to 110/60 C) Serial BP checks and neuro checks, no treatment for now

4. Goal Blood Pressure for a patient with Diabetes or Renal disease is: A) <100/60 B) <120/70 C) <130/80 D) <135/85 E) <140/90

5. Patients who are normotensive at age 55 have what percentage chance of developing hypertension? A) 25% B) 50% C) 75% D) 90%

6. Compelling indications for mortality improving certain types of antihypertensives in special co-morbidities include: A) Congestive Heart Failure B) Known Coronary Artery Disease C) High Risk Status for CAD, > 20% D) Diabetes E) All of the above

7. Women in child bearing years are best managed with what antihypertensive? A) An ACE Inhibitor B) A Diuretic C) A Beta-blocker

8. Blood pressure 20/10 above the goal blood presure would indicate what treatment? A) Lifestyle changes, recheck in 6 months B) Monotherapy with alpha-methyldopa C) Double drug therapy with a diuretic and an ACE inhibitor

9. Important components for a follow-up exam include: A) Review of diet and exercise B) Compliance with medications C) Side effects of medications D) Cost issues E) All of the above

10. The proper method of measuring BP is: A) Lying on the exam table, left arm superior, with a cuff bladder encircling 50% of the arm B) Sitting on the exam table, with cuff bladder encircling the arm 50%, with the nurses initial BP C) Sitting on the exam table, after sitting for 5 minutes, with cuff bladder encircling the arm 80%, with nurse repeat BP D) You or the nurse obtain the elevated BP after sitting for 5 minutes in a chair with feet on the floor, arm supported heart level, with cuff bladder encircling the arm 80%

Welcome to the Obesity Study Module for the Obesity Focused Clinic. There are a number of excellent resources on the Internet on the subject of obesity. I would like to introduce you to an important one called “Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults”. This was developed by the National Heart, Lung and Blood Institute Obesity Education Initiative, and sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases. An expert panel made up of 24 members, and 115 outside reviewers performed a systematic review of the literature using MEDLINE from January 1980 through September 1997, and chose 236 randomized controlled trials to develop the following guidelines.

TASK ASSIGNMENTS:

Go to Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults home page and read the Executive Summary

The complete text can also be viewed online — same home page as above — click on “Electronic Textbook” — it is worthwhile to bookmark this page for future reference.

Take the Post-test and submit your answers.

From the same home page as above — download the free PDA software program labeled “Obesity Guidelines for the Palm”. This is an excellent tool that you can use at the bedside. It not only includes a copy of the executive summary text, but also includes an interactive assessment tool that you can actively use with your patient right in the exam room — it allows you to calculate the patient’s BMI, and perform a risk assessment. This will then help you develop a management strategy for your patient and suggest to you what your patient may require, e.g. lifestyle change, diet, exercise, pharmacotherapy, etc.

Obtain the free PDA software program called “Ideal Body Weight v.2.1” from David Acosta, MD — he can beam this to you for your Palm, or you can download it yourself at http://www.useabledata.com (click on “Medical Apps”, and select “Ideal Body Weight”) — it will allow you to calculate your patient’s ideal body weight, BMI, and classify obesity.

Read Drug Therapy for Obesity, by Susan Rowe, R.Ph., 8/5/2003

EpicCare SmartText

Find the SmartText labeled “TFMObesity_Initial Visit” to guide you through your initial visit and help you document pertinent information.

For followup visits, find the SmartText labeled “TFMObesity_FUvisit” to use as a guide and help you document.

ADDITIONAL RESOURCES:

Organizations

American Obesity Association

Shape Up America!

Algorithm for Weight Management

Visualizing the sometimes circuitous process of weight management can be helpful in the therapeutic setting. Print out this physician’s aid for quick reference.

Choosing a Safe and Successful Weight Loss Program (patient education)

Diets

Food Exchange List

Sample Reduced-Calorie Menus(1200 through 1600 calorie diets, with sample diets for cultural diverse populations)

Sample Diets (1200 through 2000 calorie diets, with sample diets for cultural diverse populations)

Shopping For Food: What to Look For (patient education)

Counseling

Guide to Behavioral Change (patient education)

Counseling Your Patients About Weight Loss

Guide to Physical Activity (patient education)

Diagnostic Codes for Treating Obesity & Co-Morbidities

Introduction:

Stroke is the third leading cause of death in the US and is associated with significant morbidity and healthcare costs. Every year approximately 500,000 individuals suffer a first stroke and more then 200,000 suffer a subsequent stroke. The frequency of stroke doubles every 10 years after age 55 (1). Risk factors for stroke, as outlined in a concensus statement from the National Stroke Association, include six medical conditions: hypertension, myocardial infarction, atrial fibrillation, diabetes mellitus, hyperlipidemia, asymptomatic carotid artery stenosis, and four lifestyle risks: smoking, alcohol use, physical inactivity and high fat diet. The National Stroke Association recommends vigorous identification, evaluation and alteration of an individual’s risk factors for stroke (2).

Module Objectives:

• Understand the pathophysiology for development of stroke in patients with atrial fibrillation
• Review preventive measures for stroke in patients with atrial fibrillation
• Understand risk stratification for stroke in patients with atrial fibrillation
• Develop a patient specific preventive strategy based on risk factors and medication characteristics

1. The lifetime prevalence of back pain exceeds what percentage in most industrialized countries? a. 20-30% b. 40-50% c. 60-70% d. 70-80%

2. Disability from low back pain is second only to the common cold as a cause of lost work time and is the most common cause of disability in persons under age 45. True False

3. Most back pain is self-limiting, with 50-60% of patients showing improvement regardless of treatment. True False

4. What percentage of patients with low back pain are hospitalized? a. 3% b. 10% c. 25% d. 40%

5. What percentage of patients have surgery as a result of a given episode of low back pain? a. 0.5% b. 1.0% c. 3.5% d. 10%

6. What percentage of patients are considered totally disabled from chronic low back pain, and what percentage are considered partially disabled in the U.S.? a. Total: 2%, partial: 5% b. Total: 5%, partial: 15% c. Total: 10%, partial: 25% d. Total: 25%, partial: 40%

7. Although there is a high remission rate, the recurrence rate for low back pain is also high. What percentage of patients with acute low back pain will suffer at least 1 additional episode which will last longer and produce more severe symptoms? a. 30-40% b. 40-50% c. 50-60% d. 60-70% e. 70-80%

8. Name at least 5 (out of the 18) diagnostic and prognostic red flags in cases of low back pain.

9. Describe what the following maneuvers specifically test for, and how to perform them. a. Straight leg raise

b. Crossed straight leg raising test (Fajersztajn test).

c. Patrick’s Test

d. Sacroiliac provocation test

1. What do the following findings on physical exam in a patient with low back pain signify? (please be specific) a. Absence of patellar reflex

b. Presence of heel drop

c. Absence of the Achilles reflex

d. Weakness of the extensor digitorum longus and extensor hallucis longus.

1. In general, most patients with low back pain will recover (90%) in 4-8 weeks, and no laboratory or diagnostic procedures are usually recommended for the routine workup unless there are red flags present. Name 5 indications for obtaining lumbosacral (LS) radiographs.

2. Name 3 indications for CT or MRI.

3. What are the 3 primary goals of management of low back pain?

4. Prolonged bedrest has proven to be detrimental, as it causes deconditioning, and should be limited to only 5 days. True False

5. Muscle relaxants have been studied and found to be better than placebo in both acute and chronic muscle spasm. True False

6. Ultrasound should not be used if a disk herniation is suspected, especially if the patient had a previous laminectomy. True False

7. In a recent study, neither lumbar support nor education led to a decrease in low back pain incidence or sick leave. True False

8. In following a patient that has both back pain and sciatica, what things should they immediately call someone for?

9. What are the indications for emergent surgery in a low back pain patient?

10. What is cauda equina syndrome?

Follow-up visit

History

Symptoms of target organ disease, uncontrolled HTN

Log or BP measurements

Lifestyle review, 24 hour diet recall

Review of medications, side effects and compliance Physical Exam

focused cardiovascular Labs

followup of impact of meds on electrolyte and renal function Assessment

JNC 7 categories, controlled or not, compliant or not

JNC 7 compelling indications

Reversible cardiac risks that need attention

Other Co morbidities Plan:

Diagnostic tests, any further f/u lab or lab for secondary causes indicated

Lifestyle counsel especially diet and exercise and habit

Medication adjustments EpicCare SmartTexts

Click SmartText button, hit T, scroll to TFM HTN F/U

Goals

1. Teach basic concepts of the diagnosis and management of Chronic Heart Failure in the outpatient office setting 2. Provide an opportunity to apply the knowledge and skills learned caring for patients in the residency clinic.

Objectives

1. For patients with known suspected CHF, the resident will:

a. Gather pertinent history information relevant to risk factors, precipitating causes and common symptoms of CHF b. Perform directed physical exam, demonstrating knowledge of pertinent positive and negative exam findings correlative with CHF. c. Order appropriate lab and imaging studies to evaluate and clarify the diagnosis. d. Demonstrate knowledge of differential diagnosis of underlying causes and precipitating causes of CHF. e. Using the above information, accurately diagnose and assess the severity of CHF, then formulate a management plan in accordance with current national guidelines, including appropriate specialty consultation when indicated. f. Provide appropriate patient education about their illness.

1. The resident will be familiar with web based resources for national guideline recommendations and for patient education.

Methods

1. Readings The resident will read the following web-based resources:

A. Chronic Heart Failure. American Board of Family Practice Reference Guide, 8th edition.

http://www.familypractice.com/references/guidesframe.htm

B. ACC / AHA guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: 2001 Report of the ACC / AHA Task Force. Executive summary (from circulation):

http://circ.ahajournals.org/cgi/content/full/104/24/2996

Or selected sections of the full text report via Adobe Acrobat

http://www.americanheart.org/downloadable/heart/1013201138293HFGuidelineFinal.pdf

Overview HF &def’n pg 4-5, Stages/classification pg 6, Eval and Hx/PE pg 7-11, General tx recs pg 12-14, pharmacotherapy pg 14-25, Diastolic dysfx pg 36-38, End stage pg 28-30

Or Pocket guideline http://www.acc.org/clinical/pocket_guidelines.htm

Or Pocket guide download site for PDA http://www.acc.org/clinical/palm_download.htm

1. Use of CHF Smart Text in Epicare

When seeing patients in the module clinic with possible or known CHF, the resident will use the TFM epic smart text on Initial Evaluation or Follow up Evaluation of Chronic Heart Failure. These smart texts have distilled the current national guidelines for history, physical and lab/imaging documentation into a template for a visit note, helping to both review these concepts and provide one example for charting that fulfills expectations for appropriate documentation

Evaluation

1. The resident will precept all patients seen in the cardiology module clinic with the TFM preceptor of the day. That preceptor will provide immediate feedback to the resident re: their understanding of the concepts of the module as applied to care of specific patients. 2. The resident will successfully complete the electronic post-test for the module.

Additional Resources

Mnemonic for DDX of Acute Treatable / Precipitating Causes of CHF Decompensation “PAID HEART”

PE/ Pericardial dz Htn urgency / Hypoxia Arrthymia Endo (like thyroid, Calcium disorder) Infarct / Infection Anemia Drug / Diet (new bad drugs: NSAID, or non compliance Rheumatic (valve problem) / Renal failure w/ CHF meds, or diet, increase Na+) Tamponade

Additional Articles for Further Learning

Jessup, Mariell. Brozena, Susan.. Medical Progress: Heart Failure. New England Journal of Medicine. 348(20):2007-2018, May 15, 2003. http://content.nejm.org/cgi/content/full/348/20/2007

Gomberg-Maitland, Mardi MD. Baran, David A. MD. Fuster, Valentin MD, PhD. Treatment of Congestive Heart Failure: Guidelines for the Primary Care Physician and the Heart Failure Specialist. Archives of Internal Medicine. 161(3):342-352, February 12, 2001.

Abraham, William T. MD. Scarpinato, Len DO, MS. Higher Expectations for Management of Heart Failure: Current Recommendations. Journal of the American Board of Family Practice. 15(1):39-49, January/February 2002. http://www.jabfp.org/cgi/reprint/15/1/39

Farrell, Michael H. MD. Foody, JoAnne Micale MD. Krumholz, Harlan M. MD. [beta]-Blockers in Heart Failure: Clinical Applications. JAMA. 287(7):890-897, February 20, 2002. http://jama.ama-assn.org/cgi/content/full/287/7/883

http://jama.ama-assn.org/cgi/content/full/287/7/890

Patient Education Sites

American Heart Association link for general explanation of heart failure, tips on healthy eating, medication use, etc. http://www.americanheart.org/presenter.jhtml?identifier=1486

Mayo Clinic link for good patient information on Heart Failure: http://www.mayoclinic.com/invoke.cfm?id=DS00061

National Institutes for Health link for even more information on Heart Failure:

http://www.nhlbi.nih.gov/health/public/heart/other/hrtfail.htm

Welcome to the Low Back Pain Study Module for the Low Back Pain Focused Clinic. There are a number of excellent resources on the Internet on the subject of low back pain. I would like to introduce you to an important one published by the American Academy of Family Practice, that is one of the reference guides that is used when you recertify for your Boards. This is the same publication that is used in checking the quality of documentation in your medical charts in the office. It is now in its 7th edition.

TASK ASSIGNMENTS:

To find the monograph, go to FamilyPractice.com, the ABFP Guides home page. Click on “Reference Guides”; and on the left side panel, click on “Low Back Pain”. Read the monograph.

The complete text can also be downloaded as a PDF file if you prefer.

Take the Post-test and submit your answers.

OTHER RESOURCES:

Deyo RA, Weinstein JN. Low Back Pain. NEJM 2001; Feb 1; 344:(5):363-70

Same article in pdf format http://content.nejm.org/cgi/reprint/344/5/363.pdf (username: hslic password: winter)

Click here for summary of same article

“LBP Pearls for the Palm”, by David Acosta MD, 7/2003 - clicking on “Palm” will download the document to your computer, and then will allow you to hot sync it to your Palm. You can find it under Teal Doc, or iSilo. EpicCare

Find the SmartText labeled “TFM LBP_InitialVisit” to guide you through your visit and document pertinent information.

For followup visits, find the SmartText labeled “TFM LPB_FUvisit” to use as a guide and help you document.

1. The ADA target for HbA 1c is A. 8.0% B. 7.5% C. 7.0% D. 6.5%

2. A fasting plasma glucose of 121 is consistent with:A. Normal B. Impaired glucose tolerance C. Impaired fasting glucose D. Diabetes

3. The goal for blood pressure control in diabetes is:A. 140/90 B. 130/80 C. 138/85

4. The most accurate statement concerning eye exam for a type 2 diabetic is:A. Adequately done by the primary care physician B. Recommended annually starting 3-5 years after diagnosis C. Frequency is well established by controlled trials D. Recommended annually starting at the time of diagnosis

5. Established risk factor(s) for diabetic foot ulcers included (choose all that apply):A. Tobacco use B. Hyperlipidemia C. Foot deformities D. Loss of protective sensation

Monographs, websites and sources

JNC Express, The 7th Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, May 2003, NIH and NHLBI, website: http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm

Hypertension, reference guide 4, 9th edition, American Board of Family Practice, 2001, website:

http://www.familypractice.com/references/referencesframe.htm?main=/references/ABFPGuides/Hypertension/hypertension.htm

Hypertension: Common Conditions, PrimeAnswers University of Washington website: http://www.primeanswers.org/primeanswers/fpin/ebptutorial/

Evidence-based management of low back pain by Rick Deyo, M.D. Recently, Dr. Deyo gave a highly rated, evidence-based talk on the management of low back pain at the University of Washington based on his recent review article published in the New England Journal of Medicine, 2001*. Some of the important points he shared included:

Evidence suggests:

25-80% of causes of LBP are impossible to determine

90+% of patients with LBP get better in 6-8 weeks no matter what treatment is provided

LBP is a common, chronic disorder with intermittent exacerbation and long periods of remission When seeing a patient with LBP, Dr. Deyo suggested you ask yourself three questions:

Could a systemic disease cause this? (cancer, rheumatic disease, infection, referred pain)

Red flags indicating concern:

age > 50

history of previous cancer

fever / immunocompromised

injection drug use / skin infection / UTI

Could this be a neurologic problem? (neuropathy, nerve root impingement)

Red flags indicating concern:

L-5: weak foot, weak toe dorsiflexion, sensory loss in L-5 dermatome

S-1: decreased ankle reflex

Symptoms of spinal stenosis (usually >50yo, simian stance, OK uphill, pain downhill)

Are there significant social/psychological factors? (disability issues, secondary gain, opioid seeking)

Red flags indicating concern:

whole leg pain

consistent pain for “years”

Imaging Studies

Unless you are considering a systemic illness or neurologic problem, imaging studies are unlikely to be helpful and are often confusing. In controlled studies, many patients with highly abnormal MRI’s of the spine are totally asymptomatic.

Plain spine films are useful 1/1250 times in unselected patients with LBP Treatment

Encourage patient to be as active and exercise as much as possible (bedrest delays recovery and increases morbidity).

Transition back to work as soon as possible

NSAIDs

modest symptomatic relief during acute flare

Opioids

symptomatic relief during acute flare only. Should be time limited.

Chronic LBP and long term opioids are controversial and patient should be referred to pain clinic or specialist first

Massage, chiropractic and physical therapy all help some during acute flare

Acupuncture and other complimentary therapies have no good evidence of benefit.

• Deyo RA, Weinstein JN. Low Back Pain. NEJM 2001;344(5):363-70.

Introduction

Hypertension is the number one principal diagnosis billed for an office visit in outpatient Family Practice in 2000. Individuals who are normotensive at age 55 have a 90% chance of developing hypertension in their lifetime. Lifestyle modifications (diet, exercise and alcohol moderation) aimed at both controlling HTN and preventing atherosclerotic disease are needed in every patient. Of those requiring medicines, about 25% will be controlled with monotherapy, but most patients will require two or more medications to reach the goal BP of <140/90, (<130/80 in DM and Renal disease). In patients with HTN and additional cardiac risk factors, with stage 1 HTN (140-159/90-99) achieving a sustained 12mm reduction in systolic BP for 10 years will prevent 1 death for every 11 treated. With established CVD or target organ damage, the same reduction and length will prevent 1 death for every 9 treated.

Initial workup visit:

The content of the initial workup is more extensive and contains:

History:

Special age or ethnic group

Diagnosis and duration of HTN and prior HTN workup

Present symptoms

ROS review for hints of secondary causes of HTN, about 10% of HTN, or symptoms of active target organ damage, i.e. angina, TIA

Medications, supplements, and herbals causing HTN

Lifestyle habits diet, exercise, alcohol, drugs, and tobacco

Past Medical History of target organ damage conditions

Past Medical History of causes of secondary HTN

Family History of HTN, CAD, CVA

Social History for stress, ability to afford medicines, motivational stage to adopt lifestyle changes

CV Risk factor review

Physical:

Repeat BP with proper size cuff, and both limbs and one leg

BMI, neck and waist circumference for sleep apnea and metabolic syndrome

Fundi exam for changes

Neck exam for thyroid and carotid bruits, and JVD

Lung, heart, peripheral CV exam for cardiopulmonary

Abd exam for renal or aortic bruits

Baseline Lab:

Electrolytes, BUN, Creatinine, glucose, calcium (Chem 7);

Urinalysis, microalbumin

Lipid profile after a 9-12 hour fast

ECG

Assessment:

JNC 7 categories of optimal, <120/80, prehypertension, 120-139/80-89, Stage 1 HTN, 140-159/90-99, and Stage 2 HTN ³ 160/100

JNC 7 compelling indications for medications, CHF, post MI, high risk for CAD, Diabetes, Chronic Kidney disease, CVA

Evidence of possible secondary cause of HTN needing workup

Reversible cardiac risks that need attention

Co morbidities

Plan/Patient education:

Lifestyle counsel of weight reduction, adopting the DASH eating plan, dietary sodium reduction, increased physical activity, and moderation of alcohol consumption

Medications and their possible side effects

Addressing other active cardiac risk factors

Need for lifelong treatment

Epicare Smarttexts

Click SmartText button, hit T, scroll to TFM HTN Initial

A 58 year old female comes to your office to establish care. She states that she was diagnosd with atrial fibrillation. She has been taking in aspirin (325 mg) a day.

1) All of the following would place her in a high risk category for stroke secondary to atrial fibrillation except:A) Hypertension B) Prior embolic event C) Congestive heart failure D) Mitral valve stenosis E) Chronic obstructive pulmonary disease

2) The patient then tells you that she had an echocardiogram done six months ago, which showed an enlarged left ventricle and evidenc of congestive heart failure. What do you recommend to her in regards to pharmacologic stroke prevention?A) No therapy B) Aspirin 325 mg once a day C) Low dose warfarin plus aspirin 325 mg a day D) Warfarin to attain an INR of 2-3 E) Warfarin to attain an INR of 4-5

3) Appropriate follow up of the INR in a patient that has started warfarin would be: A) Weekly until stable, then monthly B) Every 2 weeks C) Weekly until stable, then every 3 months

D) Weekly until stable, then only if the patient complains of bleeding E) Every 6 months

A 60 year old male patient with permanent lone atrial fibrillation asks you about the most appropriate preventive medication for stroke. He has no other medical problems.

4) Which of the following medication regimens would you recommend?A) Aspirin 75 mg once a day B) Aspirin 325 mg once a day C) Warfarin to attain an INR of 2-3 D) Warfarin to attain an INR of 3-4 E) Low dose warfarin and aspirin

5) If he had a history of a previous embolic stroke but no residual deficits, which pharmacologic regimen would you recommend?A) Aspirin 325 mg once a day B) Warfarin to attain an INR of 1.6 - 2.5 C) Warfarin to attain an INR of 2.5 - 3.5

D) Warfarin to attain an INR of 4 - 5 E) No medication at this time

A 55 year old male patient of yours was recently diagnosed with atrial fibrillation, which has been present for at least 72 hours. You consult the cardiologist and make a decision to try cardioversion.

6) What do you counsel him in regards to treatment prior to cardioversion?A) He will need to take warfarin for 3-4 days before and after the procedure B) He will need to take 325 mg of aspirin for 2 weeks before and after the procedure C) He will need to take warfarin for 3-4 weeks before and after the procedure D) He will need to take aspirin for 3-4 weeks before and after the procedure E) He can undergo cardioversion immediately as he has not had atrial fibrillation long enough to increase his risk of cardioembolism

7) All of the following are risk factors for stroke except:A) Hypertension B) Atrial fibrillation C) Asymptomatic carotid artery stenosis D) Female sex E) Hyperlipidemia

8) Permanent atrial fibrillation is defined as:A) Atrial fibrillation episodes last < 7 days B) Atrial fibrillation episodes last more than one year and cardioversion has not been attempted or fails C) Atrial fibrillation in individuals without structural heart disease D) None of the above

1. Define “overweight”.

2. Define “obese”.

3. Which target population has the highest incidence of obesity?

4. Obesity is associated with all but which ONE of the following cancers?a. Nasopharynx b. Colon c. Breast d. Prostate e. Endometrial

5. Obesity is associated with which of the following chronic diseases? (check all that apply)a. Hypertension b. Osteoarthritis c. Heart disease d. Sleep apnea e. Chronic pancreatitis

6. Calculate the BMI for an adult who weighs 215 lbs., and is 5’11 tall.

7. The patient in question #6 is male. His WHR = 42”. What is his classification, and what is his associated disease risk, e.g. none, high, very high, extremely high? Obesity Classification: Disease Risk:

8. For the patient identified in question #6 and #7, what treatment strategy(ies) would you recommend?a. Diet, physical activity, & behavior therapy b. Diet, physical activity, behavior therapy, & pharmacotherapy c. Diet & physical therapy alone d. Surgery e. None of the above

9. The initial goal of weight loss therapy should be to reduce body weight by approximately what percentage from baseline?

10. Weight loss should be about how much per week for a period of 6 months, with the subsequent strategy based on the amount of weight lost?

BONUS QUESTION (optional)

How many salesmen does it take to change a light bulb?

Who cares?

I hate this joke.

One

Two

Three

Only one. But today, and today only.

What You Should Know About Generalized Anxiety Disorder

What is generalized anxiety disorder?

Generalized anxiety disorder (GAD) causes people to be worried or tense most of the time. Sometimes, they think something terrible will happen even though there’s no reason to think that it will. They may also worry about health, money, family or work. They may feel tense without knowing why.

GAD usually starts when people are in their early 20s. About 10 million adults in the United States have this disorder. Women are more likely to have it than men.

How do I know if I have GAD?

Most people worry and these occasional worries are normal. This doesn’t mean that you have GAD. You may have GAD if you can’t stop worrying and relax. As a rule, if you have GAD, you worry so much that it interferes with your day-to-day life, and it happens more days than not. Here are other signs of GAD:

Trouble falling or staying asleep Muscle tension Irritability Trouble concentrating, or your mind goes blank Getting tired easily Restlessness, or feeling “keyed up” or on edge If you feel tense most of the time and have some of these symptoms, talk to your doctor. Your doctor will probably examine you and ask some questions to make sure that something else isn’t causing your symptoms. Sometimes certain kinds of medicine may cause GAD. Your thyroid gland could be too active or you may be depressed. If your doctor doesn’t find any other reason for your symptoms, you may need to be treated for GAD.

How is GAD treated?

If you have GAD, you must learn ways to cope with your anxiety and worry. You’ll probably need some counseling to help you figure out what’s making you so tense. Also, you may need to take some medicine to help you feel less anxious. Your doctor will be able to recommend the treatment that will be best for you.

Patients with GAD can get better. If you take medicine for generalized anxiety disorder, you may be able to s taking it in the future.

To learn more about GAD, you can visit the Web site of the Anxiety Disorders Education Program at http://www.nimh.nih.gov/anxiety.

---

This handout provides a general overview on this topic and may not apply to everyone. To find out if this handout applies to you and to get more information on this subject, talk to your family doctor.

Visit familydoctor.org for information on this and many other health-related topics.

Copyright © 2000 by the American Academy of Family Physicians. Permission is granted to print and photocopy this material for nonprofit educational uses. Written permission is required for all other uses, including electronic uses.

INITIAL VISIT CONTENT

TREATMENT GOALS

ROUTINE VISIT CONTENT

MEDICATION /TREATMENT ALGORITHMS

ADA & USPSTF GRADING SYSTEMS

WEB LINKS

Latest version: 7/15/2003 DIAGNOSIS and SCREENING

Diagnostic Criteria

Normal

IFG or IGT*

Diabetes

FPG < 110 mg/dl

FPG > 110 and < 126 mg/dl

FPG > 126 mg/dl

2 hr PG < 140 mg/dl

2 hr PG > 140 and < 200 mg/dl

2 hr PG > 200 mg/dl or random plasma glucose > 200 mg/dl and symptoms

*IGT = impaired glucose intolerance IFG = impaired fasting glucose Fasting = no intake except water for > 8 hours 2 hr PG = 2 hours post 75 gm glucose load

ADA Risk Factors for Type 2 Diabetes Age > 45 years Overweight (BMI > 25) Family history of diabetes Habitual physical inactivity Race/ethnicity (African-American, Hispanic-American, Native American, Asian, Pacific Islander) Impaired fasting glucose or glucose tolerance History of gestational diabetes or delivery of infant > 9 lbs Hypertension HDL cholesterol < 35 mg/dl and/or triglycerides > 250 mg/dl Polycystic ovarian syndrome History of vascular disease

Screening No Randomized clinical trials demonstrating reduced morbidity and mortality from screening.

Preferred screen is the fasting plasma glucose. Repeat required for diagnosis confirmation. HbA1c is not used for screening or diagnosis

ADA recommendations (expert opinion)

Consider q 3 years starting age 45, particularly with BMI > 25

Consider at younger age and higher frequency if additional risks present

Children and adolescents q 2 years starting age 10 for overweight + 2 risk factors

Overweight = BMI > 85%ile for age and sex, or weight for height > 85%ile, or weight > 120% of ideal (50%ile) for height.

Risks are type diabetes in 1st or 2nd degree relative, high risk race/ethnicity (as above), signs of insulin resistance (HTN, hyperlipidemia, PCOS, acanthosis nigricans)

USPSTF recommendations: http://www.ahcpr.gov/clinic/uspstf/uspsdiab.htm

INITIAL VISIT CONTENT

ADA recommendations

http://care.diabetesjournals.org/cgi/content-nw/full/26/suppl_1/s33/T5

TREATMENT GOALS

ADA Treatment Goals:

HbA1c < 7.0% (Grade A for tight control and reduced complications, grade B for specific goal) Preprandial plasma glucose 90-130 mg/dl Peak postprandial glucose < 180 mg/dl No data concerning effects in elderly 65 or over, children < 13, and patients with advanced complications. Less stringent goals may be appropriate.

Blood pressure < 130/80 (Grade A for reduced complications, grade B for specific goal)

Lipids LDL < 100 mg/dl (Grade A for reduced cardiovascular events, B for goal) Triglycerides < 150 mg/dl HDL > 40 mg/dl ATP-III guideline secondary goal: non-HDL cholesterol (total minus HDL) < 130

American Association of Clinical Endocrinlogists has issued more stringent guidelines with goals of HbA1c < 6.5, Fasting glucose < 110, and postprandial peak < 140

http://www.aace.com/clin/guidelines/diabetes_2002.pdf

ROUTINE VISIT CONTENT

(All evidence grades are per ADA system)

Frequency q 1-2 weeks while establishing control of above parameters, then q 3-6 months

History

Patient concerns

Diet, exercise, and medication adherence

Symptoms of hypo or hyperglycemia

Review home blood glucose records

Intercurrent illness

ROS

Symptoms of complications: chest pain or anginal equivalents, paresthesias or foot ulceration, claudication, urinary symptoms, visual symptoms.

Physical

Weight (assess gain/loss)

Blood pressure

Targeted exam based on history and ROS

Foot exam for high risk (loss of protective sensation, deformity, prior ulcer, ASPVD, smoker)

Interventions

Address acute issues and patient concerns

Prn review of self-care: diet/exercise therapy, foot care, glucose monitoring, ect.

Regimen modification to meet therapeutic targets as above (BP, lipids, glucose)

Indicated periodic screenings for complications

Indicated referrals

Periodic Monitoring and Screening for Complications (add diabetic modifier in HM in EPIC)

HbA1c q 3-6 months (grade E)

Home glucose monitoring: GDM and type 1 > 3/day, type 2 adequate to reach goals

Annual spot urine for microalbuminuria (grade E, no trials showing less nephropathy)

Annual foot exam and monofilament testing for protective sensation (grade B)

Foot exam q visit if high risk (grade E)

Lipids annually and as needed to optimize therapy (grade E)

Baseline EKG

Baseline BUN/creatinine and as indicated

Prevention

Annual flu vaccine (grade C)

Pneumovax, repeat at age 65 if > 5 years since first dose (grade C)

Smoking cessation advice (grade A)

Cessation counseling/treatments (grade B)

Aspirin 75-325 mg/ day

All adults with macrovascular disease (grade A)

Consider for adults with one or more additional CV risk factors

Age > 40 (grade A)

Between age 30 and 40 (grade B)

Do not use under age 21 (Reyes syndrome risk) (grade A)

Family planning/preconception counseling for reproductive age women

Referrals

Foot ulcer + high risk foot for multidisciplinary management (grade A)

Diabetic education, self-monitoring instruction at diagnosis and as needed (grade B)

Annual dilated eye exam starting at diagnosis for type 2, 3-5 years post dx for type 1 (B)

GFR < 60 or difficulties with hyperkalemia (Grade B for less cost, delayed dialysis)

Vascular evaluation for claudication (grade C)

Specialty preventive care for high risk feet (grade C)

BP not controlled with 3 drugs (grade E)

MEDICATION AND TREATMENT ALGORITHMS

General

Aspirin as above

ACE for type 1 with/without HTN, micro or macro albuminuria (grade A)

ACE or ARB for type 2 with HTN and microalbuminuria (grade A)

ARB for type 2 with macroalbuminuria, HTN and Cr > 1.5 mg/dl (grade A)

B blocker for history of MI (grade A for reduced mortality)

B blocker, diuretic, or ACE for initial tx of HTN (grade A)

Statins to lower LDL (grade A)

Fibrates to raise HDL, lower LDL (grade B)

Antidiabetic Agents

Medication potency for lowering HbA1c:

Metformin and sulfonylureas ~ 1-1.5%

Metiglinides ~ 1%

Thiazolidinediones and alpha glucosidase inhibitors ~ 0.5-1%

Given these potencies, HbA1c elevations at 9-11% often warrant initial combination therapy, and severe elevations > 11% may warrant initial insulin therapy as control is unlikely with oral meds and absolute insulin insufficiency is highly likely.

Use ABFP monograph for detailed discussion of medications and a suggested treatment algorithm. Link goes to monograph listing, open diabetes pdf file.

http://www.familypractice.com/references/guidesframe.htm

GRADING SYSTEMS

ADA evidence grading system

http://care.diabetesjournals.org/cgi/content-nw/full/26/suppl_1/s33/T1

A. Clear evidence from well-conducted, generalizable randomized controlled trial that are adequately powered or supportive evidence from well-conducted randomized controlled trials that are adequately powered. B. Supportive evidence from well-conducted cohort studies or case-control studies. C. Supportive evidence from poorly controlled or uncontrolled studies, or weight of conflicting evidence supporting the recommendation. E. Expert consensus or clinical experience.USPSTF evidence grading system http://www.ahcpr.gov/clinic/ajpmsuppl/harris3.htm

A. Strongly recommend. Good evidence the service improves important health outcomes and that benefits substantially outweigh harms. B. Recommend. At least fair evidence that the service improves important health outcomes and that benefits outweigh harms. C. No recommendation for or against. At least fair evidence that the service can improve health outcomes, but the balance of benefits and harms is too close to justify a general recommendation. D. Recommend against. At least fair evidence that the service is ineffective or that harms outweigh benefits. I. Insufficient evidence to recommend for or against. Evidence is lacking, conflicting, or poor quality.

WEB LINKSADA Guides (updates yearly)

http://care.diabetesjournals.org/content/vol26/suppl_1/

ABFP Guides (updates q 2 years) http://www.familypractice.com/references/guidesframe.htm

USPSTF (2003 screening) http://www.ahcpr.gov/clinic/uspstf/uspsdiab.htm

After completing this aspect of the rotation, the resident will be able to:

1. Acknowledge the unique demands of a rural practice including:

   • number of hours worked per week in patient care
   • number of patients seen per week
   • the difficult patient population
   • physician isolation
   • limited resources to access for back-up
   • home visits
   • nursing home care
   • on-call demands
   • “24 hr” accessibility
   • the demands on yourself and family

2. Acknowledge some of the critical issues that rural physicians in practice face with regards to the delivery of health care in a remote community which include:

   • shortage of health care professionals, especially the lack of available consultants in other specialty fields
   • reimbursement differential for services
   • financial pressures that can threaten small hospital closure, which in turn affect your mode of practice and your referral pattern
   • geographical distance to referral center which in turn alters your mode of practice
   • staffing shortages that alters your mode of practice
   • facility limitations that affects your pattern of referral
   • administrative and leadership expectations (e.g. medical director of local nursing home, hospital committee membership, school board, etc.)

3. Understand the important role that time management plays in the rural physician’s ability to balance practice and a normal lifestyle.

4. Understand the importance of establishing good working relationships with other medical colleagues in the same community and with those in outlying areas (referral centers).

5. Understand the benefits of utilizing other community resources in the delivery of health care to the rural population, e.g. public health agencies, home health care, hospice, etc.

6. Acknowledge the many roles that a rural physician inherently accepts in their respective community outside the realms of being a physician, e.g. community leader, hospital advocate,counselor, personal friend, school board member, etc.

7. Understand the importance of identifying their own personal and social needs as a physician living in a remote community.

Classification of Atrial Fibrillation per ACC/AHA/ESC*

1) Paroxysmal Atrial Fibrillation: atrial fibrillation episodes last < 7 days, usually < 24 hours 2) Persistent Atrial Fibrillation: lasts > 7 days, may be paroxysmal if it recurs after reversion, recurrent when a patient experiences 2 or more episodes 3) Permanent Atrial Fibrillation: lasts more then one year and cardioversion has not been attempted or fails 4) Lone Atrial Fibrillation: describes paroxysmal, persistent, or permanent atrial fibrillation in individuals without structural heart disease

The incidence of thromboembolism depends in part on the type of atrial fibrillation. The majority of clinical trials have been conducted in patients with persistent or permanent atrial fibrillation. However, embolic events have been shown to occur in patients with atrial fibrillation for as little as 72 hours (3). Therefore, patients with paroxysmal atrial fibrillation should be anticoagulated if present for a substantial portion of time.

*ACC=American College of Cardiology, AHA=American Heart Association, ESC=European Society of Cardiology

Epidemiology:

Atrial fibrillation is the most common clinically significant arrhythmia seen in primary care. It affects 0.4% of the population in general, increasing with age to affect 6-10% of the population over age 75 (4). Atrial fibrillation increases the risk of stroke 6 fold when compared to patients with normal sinus rhythm and 20-30% of acute ischemic strokes are cardioembolic in origin (5). The risk of stroke in patients with untreated atrial fibrillation is approximately 6% per year (1).

Pathophysiology of Stroke in Atrial Fibrillation:

Blood stasis in the left atrium and left atrial appendage along with activation of the hemostatic system leads to intra-atrial clot formation. The clot can then pass through the left ventricle, aorta, carotid arteries and subsequently obstruct the cerebral vasculature.

Prevention Modalities:

Multiple studies have been done to evaluate both aspirin and warfarin therapy in primary prevention of stroke. Conflicting results have been obtained with regard to aspirin. However, a meta-analysis of 6 trials comparing aspirin to placebo found that aspirin decreased the incidence of stroke 22% (6). It also appears that aspirin is more helpful when used in low risk patients which will be defined later.

Adjusted dose warfarin, on the other hand, has been shown to consistently work well for stroke prevention and to be superior to aspirin in this regard. Warfarin decreases the risk of stroke by 62-68% with an absolute annual reduction of 2.7-3.1% (7). Therefore, treating 100 patients with warfarin will decrease 3 strokes per year. When compared to aspirin, warfarin decreases the risk of stroke by 2-3 times, but increases the risk of major bleeding 1.5 times (8).

Combined low dose warfarin and aspirin have been studied for use in primary stroke prevention and have been shown to cause a higher morbidity and mortality when compared to adjusted dose warfarin and should therefore not be used in this setting (9).

Risk Stratification:

The choice of treatment modality in stroke prevention must take into account the benefits of stroke prevention versus the risk of bleeding. Therefore, several studies have been done to determine risk stratification in regards to treatment choice. Based on the information obtained a number of risk models have been developed. These include:

The Stroke Prevention in Atrial Fibrillation (SPAF) investigators

The sixth American College of Chest Physicians (ACCP) Consensus Conference

Guidelines from the ACC/AHA/ESC

The pooled analysis from the five randomized, primary stroke prevention trials in patients with atrial fibrillation: BAATAF, SPINAF, AFASAK, CAFA, SPAF (10-14). All the models agreed on the following high risk features:

prior embolic event

LV dysfunction or heart failure

valvular heart disease

hypertension

older age The ACCP and ACC/AHA/ESC also included as risk factors:

DM

CAD

thyrotoxicosis

The different models varied on the age at which risk was increased independent of other risk factors:

women >75 years in SPAF

75years as high risk, and 65-75 years as moderate risk in the ACCP Consensus

75 years in the ACC/AHA/ESC guidelines The ACC/AHA/ESC guidelines are shown below.

Additional guidelines from the ACC/AHA/ESC include:

1) For primary prevention of embolism in patients over age 75 years, target a lower INR of 2 (range 1.6-2.5) 2) INR should be determined at least weekly during the initiation of oral anticoagulation therapy and monthly when the patient is stable. 3) Anticoagulate patients with atrial fibrillation lasting more than 48 hours or of unknown duration for at least 3-4 weeks before and after cardioversion (INR 2-3).

Clinical Evaluation and Assessment of Patients with Atrial Fibrillation:

Obtain a complete history and physical and update this in the chart at each visit. This should include any additional risk factors for stroke that would place the patient in a high risk category as listed above. Also include additional modifiable stroke risks such as smoking, high fat diet, alcohol use, etc. Assess the type of atrial fibrillation, duration and any pharmacologic agents the patient is taking. Also, be sure to assess the patient’s risks for potential bleed if started on anticoagulants such as history of GI bleed or intracranial bleed, is the patient at risk for frequent falls, etc.

An EKG should be present on the chart to confirm the rhythm and evaluate for any other abnormalities: previous MI, other arrhythmias, LVH. The patient should also have a CXR done at some point to assess cardiac silhouette, vasculature, lung parenchyma. A cardiac echo should be done to evaluate for valvular disease, ejection fraction, and evidence of thrombus. Laboratory studies should be done to assess TSH, lipid profile, and electrolytes and repeated as indicated.

Additional tests to consider if indicated include exercise testing, holter monitor, transesophageal echocardiogram and electrophysiological studies.

If the patient is started on adjusted dose warfarin therapy there needs to be clear documentation of management with appropriate follow up as listed previously.

Summary:

Atrial fibrillation is the most common arrhythmia seen by primary care physicians. It increases with age and is associated with an increased risk of stroke due to thromboembolism. Oral anticoagulants have been shown to decrease the risk of stroke in patients with atrial fibrillation. While there is conflicting literature in regards to the efficacy of aspirin in this setting it does seem to decrease the risk of stroke in low risk patients and is associated with less risk of bleeding then warfarin. Warfarin on the other hand has been consistently shown to decrease the risk of stroke in patients with atrial fibrillation. The risk of bleeding versus the reduction in stroke incidence must be weighed out in each patient individually. There have been multiple studies to help risk stratify those at highest risk of thromboembolism and stoke. These high risk patients are appropriate candidates for warfarin therapy. However, lifestyle, drug interactions, compliance, risk of falls, and other associated risks should be discussed prior to the initiation of adjusted dose warfarin therapy. Finally, close follow up of patients on warfarin to insure appropriate INR level should be emphasized.

Additional Reading and Resources:

American College of Cardiology American Heart Association

American Stroke Association American Academy of Family Physicians: Stroke Monograph 256, 2000 (not available online)

Bibliography:

1. Rosenfeld JA. AAFP Monograph 256: Stroke. 2000. 2. Gorelilicck PB, Saaco RL, Smith DB, et al. Prevention of a first stroke: a review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA. 1999;281:1112-1120. 3. Hart RG, Pearce LA, Rothbart RM, et al. Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy. Stroke Prevention in Atrial Fibrillation Investigators. J Am Coll Cardiol 2000;35:183. 4. Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: Executive Summary. J Am Coll Cardiol. 2001;38:1231. 5. Evans A, Kalra K. Are the Results of Randomized Controlled Trials on Anticoagulation in Patients with Atrial Fibrillation Generalizable to Clinical Practice? Arch Intern Med. 2001;161(11):1443-1447. 6. Hart, RG, Benavente O, McBride R, et al. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: A meta-analysis. Ann Intern Med 1999;131:492. 7. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994;154:1449. 8. Manning WJ, Hakan A, Furie EL, et al. Anticoagulation to prevent embolization in atrial fibrillation. Up To Date, April 2003 9. Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomized clinical trial. Lancet 1996;348:633. 10. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med 1990;323:1505. 11. SPINAF; Ezekowitz MD, Bridgers SL, Janes KE, et al. Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. N Engl J Med 1992;327:1406 12. Petersen P Boysen G, Godfredsen J, et al. Placebo-controlled, randomized trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation the Copenhagen AFASAK Study. Lancet 1989;1:175 13. Connolly SJ, Laupacis A, Gent M et al. Canadian Atrial Fibrillation Anticoagulation (CAFA) Study. J Am Coll Cardiol. 1991;18:349 14. Stroke Prevention in Atrial Fibrillation Investigators. Stroke prevention in atrial fibrillation study: Final results. Circulation 1991;84:527

1. Current guidelines emphasize tight control of:

A. Glucose B. Uric acid C. Blood pressure D. B and C E. A and C

1. Routine screening for diabetes in asymptomatic adults is proven to reduce long term morbidity:True False

2. The preferred screen for diabetes in non-pregnant patients is:A. HbA1c B. 2 hour 75 gram oral glucose tolerance test C. Random blood sugar D. Fasting plasma glucose

3. A patient presenting with HbA1c > 11% is likely to be controleed with combination oral therapy:True False

4. The most potent oral antidiabetic agent for lowering HbA1c is:A. Acarbose B. Pioglitazone C. Metformin

5. Recommended intervention(s) based on benefit shown by randomized controlled trials include:A. Aspirin therapy for macrovascular disease B. Annual screening for microalbuminuria C. Smoking cessation advice D. Annual monofilament foot exam

6. B blockers are contraindicated in diabetics.True False

7. Prognostically most significant risk factors for type 2 diabetes are:A. Pacific Islander B. Hypertension C. Polycystic ovarian syndrome D. Hyperlipidemia E. All of the above F. B and D

8. A routine diabetes follow-up visit should include:A. Weight B. Review of home blood glucose monitoring C. Blood review D. Review of recent illnesses and symptoms E. All of the above

9. EPIC allows tracking of screening tests for diabetes complications.True False

1. List at least one condition in each of the following categories that could cause or precipitate heart failure. A) Direct Myocardial Damage

B) Restriction of Ventricular Filling

C) Rhythm Disturbance

D) Volume Overload

E) Pressure Overload

1. In taking a medication history from a patient with possible or known CHF, which of the following medications are NOT likely to contribute to worsening of symptoms: Check all that apply:

A) Prednisone

F) Imipramine

B) Advil

G) Verapamil

C) Alkaseltzer

H) Chlorpropamide

D) Prozac

I) Amlodopine

E) Tums

1. Heart sound more likely to be associated with ventricular failure: A) S3 B) S4

2. Symptoms more likely associated with: (Insert letter in box) A) Right Heart Failure B) Left Heart Failure Orthopnea DOE LE edema Anorexia, N/V Cough w/exertion

3. Sign more likely to be associated with: (Insert letter in box) A) Right Heart Failure B) Left Heart Failure JVD Rales Ascites S3 Pedal Edema Narrow Pulse Pressure

4. The following medications are recommended and labeled as class 1 treatment recommendations by the ACC / AHA in the management of AHA stage C heart failure (symptomatic LV systolic dysfx) in a patient with functional NYHA class II symptoms:

A) ACEI

E) Diuretic

B) Metoprolol

F) Digoxin

C) Hydralazine

G) Nitrates

D) Spironolactone

H) Combined hydralazine / nitrates

1. Which of the following medications has been shown to improve survival in patients with systolic dysfunction heart failure:

A) ACEI

E) Thiazide

B) Metroprolol

F) Digoxin

C) Hydralazine

G) Nitrates

D) Spironocactone

H) Combin hydralazine / nitrates

1. What lab test is indicated before starting digoxin, or after adding or increasing the dose of an ACEI, spironolactone, diuretic?

2. The new AHA / ACC designation of the 4 stages of heart failure (A,B,C,D) now replace the older NYHA funcitonal classification system (class I,II, III, IV). A) True B) False

SEROTONERGIC DRUGS

MERIDIA

COMBINATION DRUGS

FAT BLOCKERS

METFORMIN

OTC, HERBS, VITAMINS

CHROMIUM PICOLINATE

It is estimated that 14% of adults are using prescription weight loss products and another 7% are using OTC weight loss medications.

Criteria for efficacy:

Use results in weight loss of at least 5% of initial body weight and maintenance of that loss.

Reduction of comorbidities such as hyperglycemia, hypertension, dyslipidemias.

Minimum of tolerable side effects. Noradrenergic drugs Suppress appetite by direct stimulation of the satiety center in the hypothalamic and limbic regions of the brain. Amphetamines have high abuse potential; there is no clinical need for these drugs in the treatments of obesity. Structurally similar drugs have appetite suppressing effects with lower risk for CNS stimulation and abuse.

Generic Name

Trade Name

Dosage Form, Strength

Dosage Regimen

DEA Schedule

Diethylpropion

Tenuate Tepanil Tenuate

Tablet: 25 mg Dospan: 75 mg Ten-Tab: 75 mg

25 mg 3 times daily, 1 hour before meals, and in mid-evening if needed. Sustained release 75mg once daily, mid-morning

IV

Phentermine

Phentermine (various mfg.) Fastin Ionamin

Tablet: 8 mg Capsule: 8 mg Sustained release capsule: 30 mg Sustained release capsule: 15, 30 mg

8 mg 3 times daily, ½ hour before meals, or 15 to 30 mg as a single daily dose before breakfast or 10-14 hours before bedtime

IV

Phenylpropanolamine

Dexatrim Pre-Meal Prolamine Acutrim 16 Hour

Capsule: 25 mg Capsule: 37.5 mg Tablet: 75 mg

25 mg 3 times daily, not to exceed 75 mg in 24 hours, or 75 mg once daily (as sustained release)

Was OTC- pulled from market in 2000 due to increased incidence in hemorrhagic stroke

Side effects: CNS stimulation, blood pressure elevation, false sense of well being, irritability, nervousness, restlessness, insomnia. After the effects have worn off, unusual fatigue or weakness, drowsiness, trembling, mental depression.

Serotonergic drugs The increased serotonin is thought to be responsible for satiation, and thereby reduces food intake. Fluoxetine (Prozac) Dosing: Recommended daily dose for weight loss id 60 mg Side effects: Anxiety, nervousness, diarrhea, and drowsiness Efficacy: Weight loss slows after first few months of therapy and is minimal by months 6 to 10.

Fenfluramine (Pondimin)- withdrawn from market 1997 Dexfenfluramine (Redux)- withdrawn from market 1997

Sibutrimine (Meridia) DEA schedule: class IV Action: Promotes appetite control by inhibiting the reuptake of norepinephrine, serotonin and dopamine. Dosing Comes in 5, 10 and 15 mg capsules. The recommended starting dose id 10 mg daily, and increase depending on patient tolerance to 15 mg daily. The 5 mg dose is reserved for patients not tolerating the 10 mg dose. Titration is dependent on blood pressure and heart rate. The safety and efficacy of use longer than 1 year has not been evaluated. Side effects: Most commonly dry mouth, constipation, and insomnia. Others include headache, increased sweating, increase in blood pressure (sometimes substantial- blood pressure must be monitored regularly), increase in heart rate. Primary pulmonary hypertension has been reported with other weight loss drugs in this class. Efficacy: Studies showed an average weight loss of 4.4 to 6.9 kg over 12 weeks. Approximate cost: $90 per month

Combination “Fen-phen” combination was tested at doses of fenfluramine 60mg plus phentermine 15 mg (half the usual dose of each drug) in 121 men and women for 210 weeks. 48 of the patients were still participating in the study at its conclusion. The adverse effects noted were dry mouth, GI symptoms such as abdominal pain, nausea, metallic taste, diarrhea and constipation, and fatigue. These studies concluded that the drugs retained their effectiveness without serious adverse events. However, widespread use of the drug combination revealed an incidence of 18 million cases per million of primary pulmonary hypertension and the occurrence of valvular heart disease.

Fat blocking drugs Orlistat (Xenical) Action: Inhibits the absorption of dietary fats. Dosing: 120 mg 3 times daily (or with each meal, may skip with non-fat meals) + multivitamin to supplement fat-soluble vitamins. Side effects: Most commonly oily spotting, flatus with discharge, fecal urgency, fatty/ oily stool, oily evacuation, increased defecation, and fecal incontinence. Side effect management: Psillium (Metamucil) 10-15 ml (12 grams) with water at bedtime, or 1 rounded teaspoonful (6 grams) with each dose, to adsorb the oily discharge, panty liners as patient adjusts to drug. Efficacy: Studies showed a weight loss of 5.6 to 6.1 kg at one year. Approximate cost: $105 per month (120 mg TID)

Metformin (Glucophage) Action: Decreases insulin resistance. Dosing: 1500 mg/day, start with 500 mg daily-> BID-> TID Side effects: GI upset, diarrhea Efficacy: Studies show 9- 13 kg weight loss at one year when combined with low carbohydrate diet. Approximate cost: $66 per month

OTC drugs, herbal, vitamin, trace elements Metabolife Contains: Vitamin E, Magnesium, Zinc, Chromium, Guarana Concentrate (40 mg naturally occurring caffeine), Ma Huang Concentrate (12 mg naturally occurring ephedrine), Bee Pollen, Ginseng, Ginger, Lecithin, Bovine Complex, Damiana, Sarsaparilla, Golden Seal, Nettles, Gotu, Kola, Spirulina Algae, Royal Jelly, L-Carnitine-L-Tartrate, Gymnema Sylvestre. Warnings: Donot use if pregnant, nursing, heart disease, thyroid disease, diabetes, high blood pressure, depression, or other psychiatric condition, glaucoma, difficulty urinating, prostate enlargement, seizure disorder, using an MAO inhibitor, or any other prescription drug containing ephedrine, pseudoephedrine, or phenylpropanolamine.

Ephedra warning: The herb industry is largely unregulated compared to FDA standards. With the market withdrawal of phenylpropanolamine, many “herbal” weight loss drugs have been marketed. Many of these contain ephedra as a pharmacologic means to stimulate metabolism. Ephedra can be referred to as many different products: ephedra herba, desert herb, ma huang, joint fir, popotillo, sea grape, teamster’s tea, and yellow horse.

What to warn your patients about: Physiologic effects: Amphetamine-like effect, stimulation of alpha-1, beta-1, and beta-2 receptors which increase heart rate, peripheral vascular resistance, and blood pressure. Many of the marketed products also contain caffeine. When used with other stimulants, ephedra use was associated with adverse effects such as heart palpitations, psychiatric effects, gastrointestinal effects, symptoms of autonomic hyperactivity, including tremor and insomnia. Dangerous drug interactions: with non-cardioselective beta blockers could result in an increased pressor effect from unopposed alpha receptor stimulation. With MAO inhibitors (isocarboxazid Ò Marplan, phenelzine ÒNardil, tranylcypromine Ò Parnate) severe hypertension can result. All patients undergoing anesthesia with halogenated general anesthetics need to stop all ephedra use prior to surgery to avoid drug interactions. Adverse effects: Hypertension, palpitation, tachycardia, stroke, and seizures. The American Association of Poison Control Centers reported 1178 adverse reactions related to ephedra in 2001. This is 64% of the adverse reactions reported secondary to commonly used herbs, but ephedra products are only 0.82% of the herbal products for sale. This translates to a 10 to 40 fold higher risk of an adverse reaction with ephedra use.

Chromium picolinate Action enhances glucose metabolism Dosing: There is no RDA, but intake of 50 to 200 mcg daily has been deemed safe. Efficacy: Anecdotal

Pricing information from Drugstore.com

In Prime Answers, go to the bottom left hand part of the frame, and find “Find retail price at Drugstore.com”

In the blank dialog box, type in the medication you are interested in and hit the “Enter” key