American College of Physicians: Internal Medicine — Doctors for Adults ®


General internal medicine update

De-bunking current medical myths

By Linda Gundersen

The moderators at this year's update in general internal medicine will cover a broad array of studies that challenge some long-held assumptions. Darrell W. Harrington, ACP Member, associate professor of clinical medicine and chief of the division of general internal medicine at Harbor-UCLA Medical Center and David Geffen School of Medicine at UCLA, and co-moderator Mark T. Munekata, ACP Member, MPH, will discuss challenges in vascular medicine, gender-based medicine, common office-based problems, and much more.

Vascular disease

ACE-inhibitors. ACE-inhibitors do not prevent the onset of diabetes in patients with coronary artery disease and impaired glucose, according to new data in New England Journal of Medicine from the DREAM Trial Investigators (2006;355: 1551-1562). ACE-inhibitors have been hyped for some time as having this benefit. According to Dr. Harrington, using ACE-inhibitors for indications not supported by data is a position strongly advocated by the pharmaceutical industry.

He cautioned, "Physicians should reserve the use of ACE-inhibitors for specific indications as opposed to broad applications unsupported by data."

Another study on ACE-inhibitors in women of childbearing age could change routine office practice. The New England Journal of Medicine study, by Cooper and colleagues (2006;354: 2443-2451), showed that pregnant women in the first trimester who took ACE-inhibitors were at increased risk for major congenital malformations. Previous data suggested that complications were most likely to occur in the second and third trimester, so physicians had time to stop the medication before damage occurred.

"We will need to carefully screen or counsel this patient population before prescribing ACE-inhibitors to determine if they are pregnant or plan to become pregnant," Dr. Harrington said.

Diabetes. A study in New England Journal of Medicine by Kahn and others (2006;355: 2427-2443) substantiates the belief held by some experts that patients with type II diabetes do better with multiple therapies than with monotherapy.

"This again flies in the face of what's being popularized by pharmaceutical companies that claim their drug is the best or the only one needed," Dr. Harrington said. He Dr. Munekata, associate clinical professor of medicine at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, will also review two studies that may reveal patient compliance is greater than many physicians previously thought, and will advocate a greater focus on lifestyle changes.

Clopidogrel. Clopidogrel has had somewhat of a reputation as a miracle anti-platelet drug, but a new study shows that aspirin alone is just as effective as a combination of clopidogrel and aspirin. "This study is another myth buster because it contradicts data from the well-popularized COMET trial. We're suggesting routine aspirin therapy for primary prevention for cardiovascular events without adding costly antiplatelet agents," Dr. Harrington said.

He added the caveat that patients with drug-eluting stents may fall under a different protocol, as there have been reports of patients stopping their clopidogrel and developing thrombosis in the stent.

Carotid artery disease. Stenting of the carotid artery does not seem to be as effective as open carotid endarterectomy, according to new data from New England Journal of Medicine by Mas and colleagues (2006;355: 1660-1671). This is the first large, randomized clinical trial to compare the procedures. According to Dr. Harrington, the medical community is sometimes too eager to embrace new procedures, especially when they are less invasive.

He cautioned, "We shouldn't be too quick to jump into new technology without evidence that it works and that it's safe."

Lifestyle modification. The moderators will discuss data from the PREMIER trial, published in Annals of Internal Medicine by Elmer and colleagues (2006;144: 485-495), which found that prehypertensive patients sustained multiple lifestyle modifications over 18 months that improved blood pressure.

"We think that patients never do what we tell them to do, but this study suggests otherwise-and that outcomes are affected," Dr. Harrington said.

Gender-based medicine

Prostate cancer screening. A study by Walter in JAMA (2006;296: 2336-2342) suggested that prostate-specific antigen (PSA) testing to screen for prostate cancer is not helpful in older adult patients. Drs. Harrington and Munekata will discuss the broad impact of this and similar studies, which oppose many routine screenings in the elderly.

Osteoporosis. The moderators will argue the findings from a Women's Health Initiative (WHI) study published in New England Journal of Medicine (2006;354:669-683) that suggested that calcium plus vitamin D supplementation does not work in preventing osteoporosis in postmenopausal women. Drs. Harrington and Munekata said that an inadequate dose of vitamin D was used in the trial. Dr. Harrington again advocated lifestyle modifications. "Resistance training, in particular, is extremely important for women," he said.

Black cohosh. More data are bolstering the argument that black cohosh, thought by some patients and physicians to help with benign prostatic hyperplasia (BPH), is not an effective treatment. Black cohosh has also been touted as a helpful treatment in alleviating symptoms of menopause. Dr. Harrington argued that, while botanicals may or may not work, they should undergo the same stringent regulatory protocol that other pharmaceutical products do.

Common office-based problems

The moderators will review a plethora of problems seen in day-to-day practice, including:

  • soft-tissue infections from MRSA and importance of immediate empiric therapy,

  • new guidelines on asthma therapy and a study on the risks of long-term beta agonist use,

  • strategies to help patients get on board with smoking cessation, including a review of pharmaceutical therapies,

  • data from the SPORT trial on nonsurgical versus surgical interventions in low back pain suggesting that ultimately, both interventions result in the same outcome, and

  • a study suggesting a broad patient population is indicated for beta blocker use, argued by Drs. Harrington and Munekata.

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