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

Advertisement

ACP InternistWeekly



In the News for the Week of December 17, 2013




Highlights

Multivitamins ineffective, not justified, studies conclude

Most multivitamin supplements are ineffective and do not prevent chronic disease or death, and their use is not justified, concluded 3 studies and an editorial in the Dec. 16 Annals of Internal Medicine. More...

Diuretics, statins associated with diabetes onset in high-risk patients

Starting a diuretic or a statin in patients with impaired glucose tolerance significantly increased their risk of developing diabetes, a study found. More...


Test yourself

MKSAP Quiz: 3-month history of left knee pain

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. Following a physical exam, lab results and a radiograph, what is the next best step in management? More...


Cancer

Docetaxel may prolong prostate cancer survival in patients with metastasis

Docetaxel added to the start of hormone therapy for metastatic prostate cancer may prolong survival compared to patients who received hormone therapy alone, according to early results from a trial. More...

Anastrozole may be effective for primary prevention of breast cancer in high-risk, postmenopausal women

A new study partially funded by industry indicated that the aromatase inhibitor anastrozole may be effective for primary prevention of breast cancer in high-risk, postmenopausal women, although an accompanying commentary did not agree. More...

Discuss options with patients to increase colorectal cancer screening rates

Yul Ejnes, MD, MACP, continues his monthly column at KevinMD.com, discussing how physicians can increase screening rates for the second leading cause of cancer-related deaths in the U.S. More...


Gastroenterology

Long-term use of acid-suppressive drugs associated with vitamin B12 deficiency

Long-term use of proton-pump inhibitors (PPIs) and histamine-2-receptor antagonists (H2RAs) may be associated with vitamin B12 deficiency, according to a new study. More...


CMS update

CMS announces ICD-10 testing week

ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets on Oct. 1, 2014. CMS has announced a national ICD-10 testing week to help direct submitters (clinicians and clearinghouses) with the transition to the new codes. More...

Deadline for eRx incentive approaching

Physicians and other eligible professionals have until Dec. 31, 2013, to report at least 25 successful electronic prescribing (eRx) transactions to earn a 0.5% bonus on total allowed charges for professional services covered by the Medicare Part B Physician Fee Schedule during 2013. More...


From the College

ACP LEAD transition deadline reminder

Members currently pursuing an ACP Leadership Enhancement and Development (LEAD) Certificate must declare their intent to complete the requirements by e-mailing ACP at LEAD@acponline.org by Dec. 31, 2013. More...


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...

Editorial note: ACP InternistWeekly will not be published for the next two weeks due to the holidays.


Physician editor: Philip Masters, MD, FACP



Highlights


.
Multivitamins ineffective, not justified, studies conclude

Most multivitamin supplements are ineffective and do not prevent chronic disease or death, and their use is not justified, concluded 3 studies and an editorial in the Dec. 16 Annals of Internal Medicine.

annals.jpg

In the first study, a substudy of The Physicians' Health Study II, long-term use of a daily multivitamin did nothing to slow cognitive decline among men 65 and older.

Researchers randomly assigned 5,947 male physicians aged 65 and older to take either a daily multivitamin or placebo for 12 years. After an initial cognitive assessment, the men were given an average of 5 tests of global cognition, verbal memory, and category fluency by telephone 3 more times at approximately 2, 6, and 10 years. The secondary end point was a verbal memory score combining 4 tests of verbal memory, which is a strong predictor of Alzheimer's disease.

No difference was found in mean cognitive change over time between the multivitamin and placebo groups or in the mean level of cognition at any of the assessments. Specifically, the mean difference in cognitive change over follow-up was −0.01 standardized unit (SU) (95% CI, −0.04 to 0.02 SU) when treatment was compared with placebo. Similarly, cognitive performance did not differ between the multivitamin and placebo groups on the verbal memory score (mean difference in cognitive change over follow-up, −0.005 SU; 95% CI, −0.04 to 0.03 SU).

A second study found that high doses of multivitamins and minerals did not protect against secondary cardiovascular events in stable patients receiving appropriate care after myocardial infarction (MI).

Researchers at 134 U.S. and Canadian academic and clinical sites conducted a double-blind, placebo-controlled, 2×2 factorial, multicenter, randomized trial of 1,708 patients aged 50 years or older who had had an MI at least 6 weeks earlier and had serum creatinine levels of 176.8 µmol/L (2.0 mg/dL) or less. For a median of 31 months, patients were randomly assigned to an oral, 28-component, high-dose multivitamin and multimineral mixture or placebo with a primary end point of time to total death, recurrent MI, stroke, coronary revascularization, or hospitalization for angina.

The primary end point occurred in 230 (27%) patients in the vitamin group and 253 (30%) in the placebo group. The Kaplan–Meier 5-year event rate estimates were 34.2% for the vitamin group and 37.0% for the placebo group (hazard ratio, 0.89; 95% CI, 0.75 to 1.07; P=0.21). The composite of cardiovascular death, MI, or stroke occurred in 94 (11%) patients in the vitamin group and 115 (13%) in the placebo group (hazard ratio, 0.82; 95% CI, 0.62 to 1.07; P=0.142).

Serious adverse events occurred in 124 (15%) vitamin recipients and 103 (12%) placebo recipients (difference, 3 percentage points; 95% CI, −0.7 to 5.7 percentage points). Adverse events included 12 (1.4%) incident neoplasms in the vitamin group and 11 (1.3%) in the placebo group (difference, 0.1 percentage point; 95% CI, −0.8 to 1.3 percentage points). No evidence suggested harm from vitamin therapy in any category of adverse events, although researchers cautioned that a considerable nonadherence and withdrawal rate limited the study's ability to draw firm conclusions, particularly about safety.

The third article was previously published online Nov. 12. A review by the U.S. Preventive Services Task Force of 26 studies (24 randomized, controlled trials and 2 cohort studies) examined the benefits and harms of using vitamin and mineral supplements for primary prevention of cardiovascular disease (CVD), cancer, or all-cause mortality in healthy individuals without known nutritional deficiencies. It found insufficient evidence that multivitamins prevent cancer, cardiovascular disease or death.

Two large trials (n=27,658) reported lower cancer incidence in men taking a multivitamin for more than 10 years (pooled unadjusted relative risk, 0.94; 95% CI, 0.89 to 1.00). The study that included women showed no effect in them. High-quality studies (k=24; n=324,653) of single and paired nutrients (such as vitamins A, C, or D; folic acid; selenium; or calcium) were scant and heterogeneous and showed no clear evidence of benefit or harm. Neither vitamin E nor β-carotene prevented CVD or cancer, and β-carotene increased lung cancer risk in smokers.

Editorialists responding to the studies urged adults to stop using dietary supplements. First, the editorial stated, other reviews and guidelines have consistently found null results or possible harms from dietary supplements. Despite this, multivitamin supplement use among U.S. adults has been increasing.

The editorialists wrote, "The message is simple: Most supplements do not prevent chronic disease or death, their use is not justified, and they should be avoided. This message is especially true for the general population with no clear evidence of micronutrient deficiencies, who represent most supplement users in the United States and in other countries. ... Although available evidence does not rule out small benefits or harms or large benefits or harms in a small subgroup of the population, we believe that the case is closed—supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful. These vitamins should not be used for chronic disease prevention. Enough is enough."


.
Diuretics, statins associated with diabetes onset in high-risk patients

Starting a diuretic or a statin in patients with impaired glucose tolerance significantly increased their risk of developing diabetes, a study found.

Researchers reanalyzed data from the multinational Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research (NAVIGATOR) trial. They looked at patients who started taking 1 or more of the drug classes for the first time during the study's 5-year follow-up: 915 patients on beta-blockers, 1,316 on diuretics, 1,353 on statins, and 1,171 on calcium-channel blockers (the metabolically neutral control group). Results were published by BMJ on Dec. 9.

After adjustment for baseline characteristics and time-varying confounders, a significant association with new-onset diabetes was found with diuretics (hazard ratio [HR], 1.23; 95% CI, 1.06 to 1.44) and statins (HR, 1.32; 95% CI, 1.14 to 1.46) compared to the group as a whole. Beta-blockers increased risk of diabetes by an insignificant amount (HR, 1.10; 95% CI, 0.92 to 1.31) and an insignificant decrease in risk was seen with calcium-channel blockers (HR, 0.95; 95% CI, 0.79 to 1.13).

The increase in diabetes found with diuretics and statins is similar to results from previous studies, the authors said, although the current study is larger and highlights the greater risk faced by patients with impaired glucose tolerance at baseline. According to their calculations, 1 additional case of diabetes would occur in 5 years for every 17 such patients given a diuretic and every 12 patients given a statin. Other studies have also shown an increase in diabetes with beta-blockers, and the trend toward an increase in risk found in this study is not inconsistent with that possibility. A larger sample size would be needed to detect an effect from beta-blockers, the authors said.

As an observational analysis, this study is limited by the risk of confounding, although the use of calcium-channel blockers as a control was meant to correct that, the authors noted. The data also did not include information on the specific drug within a class or dosage used, both of which have been previously shown to be factors in diabetes risk. The study's findings should be confirmed in prospective randomized trials, the authors said. In the interim, however, glycemia should be better monitored in patients with impaired glucose tolerance who are prescribed these drugs, they recommended.



Test yourself


.
MKSAP Quiz: 3-month history of left knee pain

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed.

mksap.gif

On physical examination, vital signs are normal. BMI is 32. Range of motion of the left knee elicits crepitus. There is a small effusion without redness or warmth and tenderness to palpation along the medial joint line. Testing for meniscal or ligamentous injury is negative.

Laboratory studies, including complete blood count and erythrocyte sedimentation rate, are normal.

Radiographs of the knee reveal medial tibiofemoral compartment joint-space narrowing and sclerosis; small medial osteophytes are present.

Which of the following is the next best step in management?

A: Add celecoxib
B: Add glucosamine sulfate
C: MRI of the knee
D: Weight loss and exercise

Click here or scroll to the bottom of the page for the answer and critique.


.

Cancer


.
Docetaxel may prolong prostate cancer survival in patients with metastasis

Docetaxel added to the start of hormone therapy for metastatic prostate cancer may prolong survival compared to patients who received hormone therapy alone, according to early results from a trial.

The National Institutes of Health released early results from a randomized controlled clinical trial on Dec. 5. The independent data and safety monitoring committee overseeing the trial recommended that the study results become public after a planned interim analysis showed a prolongation in overall survival. Full details from the early analysis will be presented at a scientific meeting in 2014 and in a peer-reviewed publication.

Researchers enrolled 790 men with metastatic prostate cancer between July 2006 and November 2012. All patients started treatment with androgen deprivation therapy (ADT) and then received either ADT alone or ADT with docetaxel every 3 weeks for 18 weeks.

There was a significant improvement in the overall survival among patients who had received docetaxel with ADT (69%) compared to the ADT alone (52.5%). About two-thirds of patients in the study had metastasized disease that had spread to major organs, had resulted in 4 or more bone lesions, or both. This group accounted for most of the benefit in the overall survival (3-year survival rates of 63.4% on docetaxel and ADT vs. 43.9% on ADT alone).

The researchers noted that while docetaxel is approved in the U.S., its toxicity means that use should be restricted to patients with high-extent metastatic prostate cancer, the group of patients who experienced the most benefit in the current analysis.

"The results of this study are practice-changing," said the lead investigator in a press release. "We have strong scientific evidence that patients with the most advanced metastatic prostate cancer benefit from the early addition of docetaxel to ADT and not waiting until the cancer has progressed on hormonal therapy. The findings of this study are important both for improving the clinical care we deliver now and in designing new clinical trials as we strive to further improve the lives of men with metastatic prostate cancer."


.
Anastrozole may be effective for primary prevention of breast cancer in high-risk, postmenopausal women

A new study partially funded by industry indicated that the aromatase inhibitor anastrozole may be effective for primary prevention of breast cancer in high-risk, postmenopausal women, although an accompanying commentary did not agree.

IBIS-II (International Breast cancer Intervention Study II) was a randomized, double-blind, placebo-controlled trial comparing anastrozole, 1 mg orally per day, with matching placebo. Women from 18 countries were recruited for the trial from Feb. 2, 2003, to Jan. 31, 2012, if they were 40 to 70 years of age and were at increased risk for breast cancer. The primary end point of the study was histologically confirmed breast cancer, defined as invasive cancer or noninvasive ductal carcinoma in situ. The study, which was funded in part by Sanofi-Aventis and AstraZeneca, was published online Dec. 12 by The Lancet. Sanofi-Aventis and AstraZeneca also provided the study drug and matching placebo.

A total of 1,920 women were assigned to receive anastrozole and 1,944 were assigned to receive placebo. At study entry, the women's median age was 59.5 years; 695 women (18%) were older than 65 years. Over a median follow-up of 5 years, 40 women taking anastrozole developed breast cancer versus 85 taking placebo (2% vs. 4%; hazard ratio, 0.47; 95% CI, 0.32 to 0.68; P<0.001). Invasive estrogen-receptor-positive tumors were significantly less common in the anastrozole group than in the placebo group, but no difference for invasive estrogen-receptor-negative tumors was seen. The authors predicted a cumulative breast cancer incidence of 5.6% in those taking placebo and 2.8% in those taking anastrozole after 7 years.

Eighteen women died in the anastrozole group and 17 died in the placebo group, with no cause of death being more common in either group. Many side effects were reported, with musculoskeletal adverse events, vasomotor symptoms, hypertension and dry eyes being more common in the anastrozole group and vaginal or uterine prolapse and vaginal pruritus being more common in the placebo group. Thromboembolic events, cerebrovascular events and myocardial infarction did not differ between groups.

The authors acknowledged that trials with longer follow-up could more thoroughly confirm anastrozole's protective effects, especially over the long term, and that more data are needed in women with dense breasts. However, they concluded that anastrozole reduces the risk of invasive estrogen-receptor-positive breast cancer and ductal carcinoma in situ by more than 50%, more than has been reported for tamoxifen or raloxifene. They noted that although many of the reported side effects are often seen with estrogen deprivation, rates were only slightly higher with anastrozole compared with placebo.

"Our results strongly support the use of anastrozole for preventive treatment of high-risk postmenopausal women," the authors wrote.

However, the author of an accompanying commentary pointed out that the study did not detect a difference in breast cancer or all-cause mortality with anastrozole and that the literature does not yet support a gain in overall breast cancer mortality with any primary chemoprevention, since the most protection has been seen in hormone-sensitive tumors and tumors detected by screening.

"Therefore, for any woman considering 5 years' anti-oestrogen therapy to reduce her risk of breast cancer without evidence to suggest that she will have a longer life, the perceived and actual toxicity of this intervention becomes important," the commentary author wrote. "The financial costs of breast cancer chemoprevention might have decreased, but the toxicity cost to women has not."

The commentary also addressed the side effects experienced by women in the current study, noting that although the increased frequency of musculoskeletal and vasomotor events was relatively modest with the study drug compared with placebo, "more than 100-200 additional women had these symptoms in the anastrozole group compared with the placebo group—quite often to a moderate or severe level—to prevent 15 symptomatically diagnosed breast cancers."

The commentary author quoted the editorial that had accompanied IBIS-I in 2002, which had laid out 3 criteria to be met before chemoprevention could assume a prominent role in breast cancer treatment: long-term proof that reduced incidence translates to reduced breast cancer mortality, development of new drugs with better safety profiles, and development of targeted drugs for those likely to derive the most benefit.

"Unfortunately, although [the current authors] report important data, IBIS-II has not addressed any of these challenges," the editorialist concluded.


.
Discuss options with patients to increase colorectal cancer screening rates

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com. In his latest post, Dr. Ejnes discusses how physicians can help to increase screening rates for the second leading cause of cancer-related deaths in the U.S.



Gastroenterology


.
Long-term use of acid-suppressive drugs associated with vitamin B12 deficiency

Long-term use of proton-pump inhibitors (PPIs) and histamine-2-receptor antagonists (H2RAs) may be associated with vitamin B12 deficiency, according to a new study.

Researchers used data from patients who were part of the Kaiser Permanente Northern California (KPNC) network to perform a nested case-control study evaluating whether use of acid-suppressive therapy was associated with deficiencies in vitamin B12. Pharmacy, laboratory and diagnostic databases were used to determine individuals' exposures and outcomes. Cases were KPNC members who were at least 18 years old, who had been members for at least a year before the index date, and who were initially diagnosed with vitamin B12 deficiency between January 1997 and June 2011. For each case, a maximum of 10 matched-control KPNC members without a vitamin B12 deficiency at the time of the case diagnosis were selected.

Results appeared in the Dec. 11 Journal of the American Medical Association.

A total of 25,956 cases and 184,199 controls were included in the final analyses. Most case-patients were female (57.4%), of non-Hispanic white ethnicity (68.4%) and at least 60 years old (67.2%). Overall, 3,120 case-patients (12%) and 13,210 (7.2%) controls received 2 or more years' worth of PPIs; 1,087 case-patients (4.2%) and 5,897 controls (3.2%) received 2 or more years' worth of H2RAs without PPIs; and 21,749 (83.8%) case-patients and 165,092 controls (89.6%) had not been prescribed either type of drug.

Increased risk for vitamin B12 deficiency was associated with 2 or more years' worth of either PPIs and H2RAs (odds ratios, 1.65 [95% CI, 1.58 to 1.73] and 1.25 [95% CI, 1.17 to 1.34], respectively). Higher doses of PPIs (>1.5 pills/d) had a stronger association with risk for vitamin B12 deficiency than lower doses of PPIs (<0.75 pills/d), with odds ratios of 1.95 (95% CI, 1.77 to 2.15) and 1.63 (95% CI, 1.48 to 1.78) (P=0.007 for interaction). The association between PPI use and vitamin B12 deficiency weakened after the drugs were discontinued. Association of vitamin B12 deficiency with PPI use of at least 2 years was stronger among patients younger than 30 years of age and decreased as age increased; it was also stronger in women than in men.

The authors acknowledged that they did not examine associations with short-term use of acid-suppressive medications and that the calculated daily doses may not have accurately represented patients' use, among other limitations. However, although they could not rule out residual confounding in their study, they concluded that patients who use acid-suppressive medications may be at increased risk for vitamin B12 deficiency.

"These findings do not recommend against acid suppression for persons with clear indications for treatment, but clinicians should exercise appropriate vigilance when prescribing these medications and use the lowest possible effective dose," the authors wrote.



CMS update


.
CMS announces ICD-10 testing week

ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets on Oct. 1, 2014. CMS has announced a national ICD-10 testing week to help direct submitters (clinicians and clearinghouses) with the transition to the new codes.

The testing, occurring March 3-7, 2014, will give trading partners access to the Medicare Administrative Contractors (MACs) and Common Electronic Data Interchange (CEDI) for testing with real-time help-desk support. The event will be conducted virtually. Registration is required, and CMS will be posting that information closer to the event.

During testing, you can expect the following:

  • Test claims with ICD-10 codes must be submitted with current dates of service (i.e., Oct. 1, 2013, through March 3, 2014), since testing does not support future-dated claims.
  • Test claims will receive the 277CA or 999 acknowledgment as appropriate to confirm that the claim was accepted or rejected in the system.
  • Testing will not confirm claim payment or produce remittance advice.
  • MACs and CEDI will be staffed to handle increased call volume during this week.

More information is available in the MLN Matters®article MM8465, "ICD-10 Testing with Providers through the Common Edits and Enhancements Module (CEM) and Common Electronic Data Interchange (CEDI)."

ACP will also offer an ICD-10 Boot Camp as a precourse at Internal Medicine 2014 in Orlando this coming April. Expert faculty will discuss the nuts and bolts of using the new coding system, what practices need to do to implement it, how to document care to support it, and the different implications for professional fee billing and facility billing. The precourse will also cover how ICD-10 will affect the metrics now being applied by Medicare and other payers to rate clinicians and their practices. More information on the precourse is available online.


.
Deadline for eRx incentive approaching

Physicians and other eligible professionals have until Dec. 31, 2013, to report at least 25 successful electronic prescribing (eRx) transactions to earn a 0.5% bonus on total allowed charges for professional services covered by the Medicare Part B Physician Fee Schedule during 2013.

Submissions can be made through claims or approved registry or electronic health record (EHR) systems. Eligible professionals reporting through the Group Practice Reporting Option (GPRO) must meet a different defined criteria to earn the bonus, based on the size of the group. The eRx incentive is only available to clinicians who do not earn an incentive for meaningful use of an EHR in the same year.

Eligible professionals who have not earned the eRx bonus in 2012 or who have not submitted at least 10 successful eRx transactions through claims by June 30, 2013, will be assessed a 2% penalty on their Medicare Part B charges in 2014. This payment adjustment can only be avoided at this time if the eligible professional qualifies for one of the eRx Incentive Program's automatic exemptions or if the eligible professional was recognized as a participant in the Meaningful Use program by June 30, 2013.

More detailed information can be obtained on ACP's Running a Practice website.

For more information on upcoming important dates related to a variety of regulatory, payment, educational and delivery system changes and requirements (including PQRS and VBP), visit ACP's Physician and Practice Timeline.



From the College


.
ACP LEAD transition deadline reminder

Members currently pursuing an ACP Leadership Enhancement and Development (LEAD) Certificate must declare their intent to complete the requirements by e-mailing ACP at LEAD@acponline.org by Dec. 31, 2013. To earn a LEAD certificate, you must participate in 5 out of 7 LEAD activities and complete your application by June 30, 2014.

In partnership with the American College of Physician Executives (ACPE), the ACP Leadership Academy (ACP's new leadership development program designed to provide early-career internists with the skills and knowledge necessary to become leaders in medicine) is replacing ACP's LEAD program.

Former ACP LEAD certificate recipients and College members who have completed some but not all of the requirements for a LEAD certificate may transfer up to 22 credits toward completion of the prerequisites for ACPE's certificate by June 30, 2014. To determine how many credits you may transfer, please e-mail ACP at LEAD@acponline.org by Dec. 31, 2013. Applications for ACP's LEAD certificate or transfer of credits will not be accepted after this date.

For more information on the ACP Leadership Academy and LEAD transition information, visit the program website.



Cartoon caption contest


.
Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acpi-20131217-cartoon.jpg

E‑mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


.


MKSAP Answer and Critique



The correct answer is D: Weight loss and exercise. This item is available to MKSAP 16 subscribers as item 8 in the Rheumatology section. More information is available online.

Weight loss and exercise are indicated for this patient with knee osteoarthritis. Her knee pain, which is worse with weight bearing, is suggestive of tibiofemoral knee osteoarthritis, a diagnosis supported by the presence of medial joint line tenderness and radiographic findings of medial tibiofemoral compartment joint-space narrowing. The strongest risk factors for osteoarthritis are advancing age, obesity, female gender, joint injury (caused by occupation, repetitive use, or actual trauma), and genetic factors. Obesity, in particular, is the most important modifiable risk factor for knee osteoarthritis. Several trials have demonstrated that weight loss and/or exercise programs can offer relief of pain and improved function comparable to the benefits of NSAID use. In long-term studies, sustained weight loss of approximately 6.8 kg (15 lb) has resulted in symptomatic relief.

Celecoxib carries an increased myocardial risk and is therefore not appropriate for this patient who has coronary artery disease. Although celecoxib has a lower risk of gastrointestinal ulcers than other NSAIDs, it can still cause dyspepsia, which occurred in this patient after taking naproxen and ibuprofen.

There have been several contradictory studies regarding glucosamine sulfate in the management of osteoarthritis. After several favorable smaller studies, a trial sponsored by the National Institutes of Health showed no effectiveness in reducing pain. A recently conducted meta-analysis also found negative results for the use of glucosamine sulfate.

MRI of the knee would be indicated to evaluate for meniscal or other ligamentous injuries, none of which is suggested by this patient's history (the knee locking or giving way) or examination findings (negative examination for tendinous or ligamentous injury).

Key Point

  • Obesity is the most important modifiable risk factor for knee osteoarthritis, and weight loss and exercise are recommended to reduce pain and improve function.

Click here to return to the rest of ACP InternistWeekly.

Top




About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

Test yourself

A 48-year-old man is evaluated during a follow-up visit for urinary frequency. He reports no hesitancy, urgency, dysuria, or change in urine color. He has not experienced fevers, chills, sweats, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. He feels thirsty very often; drinking water and using lemon drops seem to help. He has a 33-pack-year history of smoking. He has hypertension, chronic kidney disease, and bipolar disorder. Medications are amlodipine, lisinopril, and lithium. He has tried other agents in place of lithium for his bipolar disorder, but none has controlled his symptoms as well as lithium. What is the most appropriate treatment intervention for this patient?

Find the answer

What will you learn from your Annals Virtual Patient?

Reviews of the World's Top Medical Journals—FREE to ACP Members! Annals Virtual Patients is a unique patient care simulator that mirrors real patient care decisions and consequences. CME Credit and MOC Points are available. Start off with a FREE sample case. Start your journey now.

Products and Resources for Patients

Products and Resources for PatientsACP has developed easy- to-use materials designed to help educate your patients on self-management of a wide variety of common health conditions. Order yours today!