Feb 16, 2018

It’s been 20 years since alendronate was approved to treat osteoporosis.  Although effective, bisphosphonates aren’t ideal — they have been associated with osteonecrosis of the jaw and atypical femoral fracture.1,2  Rare events, to be sure, but troubling serious adverse events that weigh on the minds of many patients and clinicians. The 2016 AACE/ACE clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis recommend the use of bisphosphonates (...

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Feb 2, 2018

There is an old adage in the fashion industry that if you wait long enough, everything comes back into style. While that may not be true (yet) for Saturday Night Fever polyester suits, it certainly seems to apply to blood pressure (BP) goals in patients with type 2 diabetes mellitus (T2DM). The seventh report of the Joint National Committee (JNC-7)1 and American Diabetes Association (ADA) guidelines for many years recommended a BP goal of <130/80 mmHg for patients with...

Comments: 1
Jan 19, 2018

Nearly 16 million adults in the United States have chronic obstructive pulmonary disease (COPD) but this is probably a woeful underestimate as many adults are asymptomatic in early stages.1,2 The United States Preventative Services Task Force recommends against screening in asymptomatic adults due to a lack of evidence that regular screening improves morbidity, mortality, or quality of life. Screening is only recommended if patients exhibit symptoms and have risk factors.3...

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Jan 5, 2018

We’ve all seen and used the American College of Cardiology 10-year atherosclerotic cardiovascular disease (ASCVD) risk calculator. There are several modifiable risk factors such as blood pressure, cholesterol, and smoking status that, if addressed, can lower ASCVD risk. But are there other modifiable risk factors that we are failing to account for and address? New evidence suggests systemic inflammation may be one.


To date, lowering levels of atherogenic cholesterol (e.g.,...

Comments: 4
Dec 8, 2017

1. Blood pressure categorizes and terminology have changed…again. The new ACC/AHA/AAPA/ABC/ACPM/ACG/APhA/ASH/ASPC/NMA/PCNA (that's a mouthful!) guidelines for the prevention, detection, evaluation, and treatment of high blood pressure (BP) in adults now have four BP categories:

  1. normal BP is systolic <120mmHg and diastolic <80mmHg
  2. elevated BP is systolic 120 to 129mmHg and diastolic <80mmHg
  3. stage 1 hypertension is ...
Comments: 4
Dec 8, 2017

Since the introduction of direct oral anticoagulants (DOACs) less than a decade ago, use of this class has expanded beyond the prevention and treatment of venous thromboembolism and stroke prevention in the setting of atrial fibrillation. Specifically, the potential role of DOACs in the secondary prevention of coronary artery disease (CAD) has been of considerable interest. Both warfarin and rivaroxaban, in conjunction with antiplatelet agents, have previously been shown to reduce recurrent...

Comments: 0
Nov 26, 2017

Asthma costs the US health care system roughly 50 billion dollars annually.1 And patients with uncontrolled severe asthma (> 2 exacerbations per year) incur far more cost than patients with persistent asthma without exacerbations ($5174 vs $1775 in 2013).2 Despite good adherence with high-dose inhaled corticosteroids (ICS) and concomitant long-acting beta agonists (LABA), millions of people continue to experience exacerbations.3  What more can patients and...

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Nov 10, 2017

Drug overdose is now the leading cause of death among Americans under the age of 50.1 This crisis has been building since the late 1990s, in part the result of rampant prescribing of opioid analgesics.2 In 2016, the United States (U.S.) Centers for Disease Control and Prevention (CDC) released a seminal guideline for primary care clinicians regarding opioid prescribing.3 These guidelines are now being implemented by clinicians, insurers, and healthcare...

Comments: 0
Oct 13, 2017

While good glycemic control has been shown to prevent microvascular complications (e.g. retinopathy, nephropathy, neuropathy), only a few anti-diabetic agents have been shown to reduce macrovascular complications (e.g. cardiovascular events.1-5  Empagliflozin, a sodium glucose transporter-2 (SGLT2) inhibitor, not only reduced the risk of CV events but also all-cause mortality in the EMPA-REG OUTCOME study.4  (See iForumRx Commentary –...

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Sep 22, 2017

Have you ever been asked about when to stop anticoagulation therapy after an unprovoked venous thromboembolism (VTE)?  If so, then you know that this decision is controversial.  According to the 2016 CHEST VTE Guidelines, at least 3 months of therapy is recommended for an unprovoked DVT or PE (Grade 1B).Thereafter, the clinician is expected to weigh the risks and benefits to determine if extended therapy is appropriate.  For patients who are at low-to-moderate bleeding risk,...

Comments: 0
Sep 8, 2017

Is self-monitoring of blood glucose (SMBG) cost-effective? There is no question that achieving good glycemic control is one means to decrease diabetes-related complications.1 SMBG is often recommended to help guide treatment decisions.  Consumer-oriented advertising often promotes frequent SMBG as means to achieve better glycemic control but current clinical practice guidelines do not provide specific recommendations regarding the frequency of blood glucose monitoring.


Comments: 8
Aug 25, 2017

Statins reduce atherosclerotic cardiovascular disease (ASCVD) risk.1,2 However, the utility of statin therapy in older adults — particularly in those age 75 years and older — remains controversial. The 2013 ACC/AHA Cholesterol Guideline does not provide specific recommendations for older adults citing a lack of evidence.3 Furthermore, the Pooled Cohort Equations estimates 10-year and lifetime ASCVD risk in adults between 40 and 75 years of age. The need for additional...

Comments: 0
Aug 11, 2017

Cabbage leaf wraps (CLWs) … the newest health craze trending on social media? A culinary masterpiece? Or an effective complementary treatment for osteoarthritis (OA) relief? A recently published study attempted to answer the latter question. Management of OA requires a multifaceted approach, including lifestyle changes, pharmacologic treatments, nonpharmacologic therapies, and occasionally surgery, depending on the severity of the patient’s pain and disability. Approximately 30 million...

Comments: 0
Jul 27, 2017

Although statins have a proven benefit and are widely used, ASCVD continues to be the leading cause of death in the US.1-3  There is documented residual CV risk apparent even in patients treated with optimally-dosed statins.1,3 However, the 2013 ACC/AHA guidelines recommend against the routine use of statin add-on therapies.1 In 2015, two proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, alirocumab (Praluent®) and evolocumab (Repatha®), were...

Comments: 2
Jun 26, 2017

Among Medicare recipients, from 2000 to 2010, there was a whopping 83-fold increase (that’s an 8300% increase!) in the number of blood tests performed to determine their vitamin D status.1 What could possibly cause such a dramatic increase?  While the aging U.S. population is at a higher risk for fractures and falls and may benefit from vitamin D supplementation, it is unlikely that this is the main driver of this phenomenon.  A more likely explanation is the fascination...

Comments: 0
Jun 10, 2017

Whether – or not - to continue anticoagulation therapy to prevent venous thromboembolism (VTE) after the initial acute treatment period requires shared decision making.  The risks and benefits are patient and situation-specific.  Numerous factors need to be considered. And the risks and benefits change over time. The EINSTEIN CHOICE study provides some important new insights to help inform this decision.1


Tens of thousands die from venous thromboembolism (VTE)...

Comments: 2
Apr 14, 2017

More than 15 million Americans have coronary heart disease and most should be taking aspirin daily.1  Given aspirin’s ubiquity in cardiovascular medicine and patients’ pill boxes, it is shocking that there are still so many unanswered questions about aspirin use.  Which dose and dosage forms should be prescribed?  How common is aspirin resistance?  What is the relationship between platelet inhibition and clinical outcomes?


The notion of aspirin “resistance” is...

Comments: 0
Mar 24, 2017

Many patients with atrial fibrillation (AF) received triple antithrombotic therapy after undergoing a percutaneous coronary intervention (PCI) and receiving cardiac stent. Triple therapy consists of warfarin plus dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor and low-dose aspirin. But is triple therapy the best approach? This practice, while widely employed, is not entirely evidence-based. It’s actually the result of combining two evidence-based strategies – one to...

Comments: 0
Mar 13, 2017

Could automated, web-based cognitive behavioral therapy (CBT) replace flesh-and-blood healthcare practitioners?  Can computers deliver healthcare at lower cost and similar quality to face-to-face interactions with humans? Several web-based CBT programs have been developed and are now being marketed directly to consumers.  But do they actually work?


According to results of the America Insomnia Survey, up to 50% of adults in the U.S. experience difficulty sleeping. Of those,...

Comments: 0
Feb 24, 2017

Hypertension affects more than 70% of patients with type 2 diabetes mellitus and further increases the risk of cardiovascular disease in this high risk population.1 While renin angiotensin system (RAS) blockers are clearly indicated in patients with heart failure, chronic kidney disease with proteinuria, and coronary artery disease (CAD), experts have come to different conclusions regarding their role as initial antihypertensive therapy for patients with diabetes (See Table 1)....

Comments: 0
Feb 9, 2017

About 5 million Americans are currently living with heart failure (HF) and an astounding 24-42% of them also suffer from depression.1,2 One meta-analysis found a greater than 2-fold risk of death in patients with HF and comorbid depression.  Depressed patients with HF are more likely to be hospitalized, seek care from emergency rooms, and rack up big bills.3  Not surprisingly, patients with HF and depression have a much lower quality of life when compared to HF patients...

Comments: 0
Jan 25, 2017

Critically evaluating the primary literature and applying the information to patient care is vital to ensuring optimal patient outcomes.  Unfortunately, the foundational knowledge and skills that most of us acquire during our formal education and post-graduate training programs are unlikely to fully prepare us for the challenges and intricacies of interpreting the evolving methods used in clinical drug studies today.  Like the development of any skill, it requires practice and refinement...

Comments: 5
Jan 13, 2017

Pharmacotherapy for diabetes management has expanded in recent years with several new drug classes. Beyond lowering A1c, some medications show promise for reducing cardiovascular risk.1-2 Current guidelines recommend several options for patients who have not reached their goal A1c on metformin monotherapy including glucagon-like peptide-1 receptor agonists (GLP-1 RAs) or basal insulin.3  However, if basal insulin is chosen as the first add-on treatment with...

Comments: 0
Dec 29, 2016

When you reach a certain age, bowel cleansing becomes a necessary poison.  Colorectal cancer is the third most common type of cancer in the United States with an estimated 95,270 new colon and 39,220 new rectal cancer diagnoses for 2016. More importantly, colorectal cancer (CRC) is the second most common cause of cancer-related mortality in the United States. Screening is imperative because the early stages of CRC are often asymptomatic1 and when combined...

Comments: 0
Dec 6, 2016

A mom recieves a prescription for an oral clindamycin solution for her daughter.  The instructions: “give one teaspoon by mouth three times daily for 10 days.”  The mom is given a medicine cup marked with “mLs”  and “tsp” on the side.  Five days later she returns complaining that she ran out of medicine.  After a brief interview, you determine that she has been giving her daughter one “cupful” instead of one “teaspoon.”


This brief case vignette is all too common.  Children...

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