2022 Guideline Update: Selected Topics in Family Medicine

Educational Objectives

The goal of this program is to improve management of common illnesses in family medicine. After hearing and assimilating this program, the clinician will be better able to:

1. Prevent cases of breast cancer and colon cancer with medication and timely screening.
2. Select the appropriate medication for treatment of patients with mild asthma.
3. Control levels of low-density lipoproteins and triglycerides in patients at risk for atherosclerotic vascular disease.

Summary

Breast cancer (BC): the second most common cause of death from cancer in women in the United States; early detection and prevention should be prioritized; women may be encouraged to, eg, increase physical activity, reduce body weight, and consume alcohol in moderation; however, clinical data is limited support to the efficacy of each intervention; magnetic resonance imaging (MRI) is a modality which promotes early detection; MRI does not prevent BC

Tools for risk assessment of BC: the BC risk tool from the National Institutes of Health is based on 6 data inputs (ie, history of carcinoma in situ, history of benign biopsies, age, family history for BC, and age of menarche and menopause); the BC Surveillance Consortium risk calculator is available as an app; the 5 data inputs are age, race, family history, history of benign breast biopsy, and breast density on mammography

Estrogen modulators: lower the amount of estrogen in blood or modulate the estrogen receptors; tamoxifen may reduce invasive BC by 7 cases/1000 patients over 5 yr; raloxifene may reduce invasive BC by 9 cases/1000 patients over 5 yr; aromatase inhibitors (eg, exemestane, anastrozole) may reduce invasive BC by 16 cases/1000 patients over 5 yr; additional benefits — patients on tamoxifen and raloxifene have lower rates of nonvertebral and vertebral fractures, respectively; aromatase inhibitors have no effect on rates of fracture; adverse effects — tamoxifen may increase venous thromboembolism by 5 cases/1000 patients over 5 yr; raloxifene may increase venous thromboembolism by 7 cases/1000 patients; aromatase inhibitors had no impact on rates of venous thromboembolism; tamoxifen slightly increases the risk for endometrial cancer and significantly increases the risk for cataracts

U.S. Preventive Services Task Force (USPSTF) guidelines: women >35 yr of age at increased risk for BC should be offered tamoxifen, raloxifene, or an aromatase inhibitor; a risk calculator should be used to assess the risk for BC; use of medications is challenging in women who are premenopausal; the focus should be on women who are postmenopausal; a 5 yr risk >3% is the threshold for use of preventive drugs; the main side effect of aromatase inhibitors is myalgias; vasomotor symptoms increase with each drug

Aspirin for prevention of pre-eclampsia: the USPSTF reviewed randomized controlled trials covering ≈16,000 patients and concluded that using aspirin in populations with elevated risk for pre-eclampsia resulted in a 15% reduction in pre-eclampsia, 21% reduction in perinatal mortality, 20% reduction in pre-term birth, and 18% reduction in intra-uterine growth retardation; use of aspirin in pregnant patients did not lead to increased risk for postpartum hemorrhage, placental abruption, or fetal intracranial hemorrhage; the risk for pre-eclampsia should be assessed early in pregnancy

High-risk factors for pre-eclampsia: the occurrence of pre-eclampsia in a prior gestation, multifetal gestation, chronic hypertension, diabetes mellitus (DM), kidney disease, auto-immune disease, or a combination of multiple moderate risk factors

USPSTF guidelines: low-dose aspirin should be prescribed after 12 wk of gestation to patients with ≥1 high-risk factor

Pneumonia: all patients >65 yr of age should receive a pneumococcal conjugate vaccine; patients <65 yr of age with risk factors (eg, immunocompromise, HIV, asplenia, end-stage or near end-stage kidney disease, cardiovascular disease, lung disease, alcoholism, chronic liver disease, DM) should be vaccinated; the pneumococcal 13-valent conjugate vaccine (Prevenar 13) is no longer recommended by the Advisory Committee on Immunization Practices; the pneumococcal 20-valent conjugate vaccine (Prevenar 20) is now recommended; patients who received the pneumococcal 15-valent conjugate vaccine (Prevenar 15) also should receive the pneumococcal polysaccharide vaccine (Pneumovax 23) 1 yr later; the second shot may be given ≥8 wk later in patients who are immunocompromised

Asthma: short-acting β-agonists for rescue therapy is the traditional recommendation for patients with mild asthma; newer recommendations include the use of inhaled corticosteroids (ICS) with a long-acting β-agonist; mild asthma may easily turn into dangerous asthma; 30% to 37% of severe asthma exacerbations, 16% of fatal asthma events, and 15% to 20% of adult asthma deaths occur in patients classified as having mild asthma; mild asthma was once thought be a disease of bronchospasm; acute or sub-acute inflammation is now thought to be a significant component of mild asthma; short-acting β-agonists may increase the risk of severe exacerbation in patients with mild asthma; ICS have been demonstrated to reduce severe exacerbations and deaths in patients with mild asthma

Treatment of asthma: the use of as-needed low-dose ICS with formoterol as rescue therapy is recommended for patients with mild asthma; formoterol is a long-acting β-agonist (similar to salmeterol), but it also has rapid onset benefits; twice daily maintenance therapy with ICS and long-acting β-agonists is recommended for patients with more severe asthma (eg, symptoms are experienced on most days); reliever medications (rescue therapy) consist of low-dose ICS plus formoterol; formulations currently available include budesonide and formoterol (Symbicort) and mometasone and formoterol (Dulera); mometasone and formoterol is not currently approved for use as rescue therapy, but this is likely to change; short-acting β-agonists may be used as rescue therapy, but an ICS should be used in combination

Pricing: albuterol costs $20 per inhaler; budesonide and formoterol is priced from $105 to $260 per inhaler, which may last 1 to 3 mo depending on usage; fluticasone and salmeterol (Advair) is priced from $107 to $130 per inhaler; ICS may cost >$200

Atherosclerotic vascular disease (ASCVD) in patients with hypertriglyceridemia: the American College of Cardiology (ACC) published an expert consensus in 2021; guidelines from the ACC published in 2018 focused on management of low-density lipoprotein (LDL) through assessing the risk for developing cardiovascular disease

REDUCE-IT trial: Bhatt et al (2019) found a 28% reduction in the rate of myocardial infarction in patients with good LDL control and hypertriglyceridemia given a triglyceride-lowering drug; the results suggest that hypertriglyceridemia may be a major contributor to cardiovascular events in patients treated with statins; the VITAL trial (Manson et al, 2012) and the ASCEND trial (Bowman et al, 2018) found no benefit from over-the-counter fish oil products in the prevention of myocardial infarction; recommendations from the REDUCE-IT trial are, eg, LDL must be controlled, and that treating patients with hypertriglyceridemia (ie, triglycerides >150 mg/dL) reduces the risk for cardiac events; no benefit was found in reducing triglycerides in patients with triglycerides ≤150 mg/dL, or without known coronary artery disease (CAD)

2021 ACC consensus statement: secondary causes of hypertriglyceridemia should be ruled out; lifestyle, diet, and blood sugar control should be optimized, and statin therapy should be maximized; further optimization of lifestyle and icosapent ethyl at 2 gm twice daily is recommended for patients with CAD, LDL <70 mg/dL, and triglycerides >150 mg/dL; for patients with LDL >100 mg/dL, the recommended approach is to maximize statins or lower LDL by other means; shared decision-making for patients with good but not ideal LDL control (70-99 mg/dL) is recommended; prescription of icosapent ethyl or a more aggressive strategy to control of LDL may be considered

Causes of hypertriglyceridemia: the most common are poorly controlled DM, consumption of alcohol, overconsumption of high glycemic index foods, and obesity; drugs (eg, β-blockers, thiazides, estrogen and estrogen modulating drugs) may exacerbate hypertriglyceridemia

Hypertriglyceridemia without ASCVD: the ACC recommends, eg, the elimination of other precipitants of hypertriglyceridemia, optimization/improvement of lifestyle; patients with triglyceride levels <500 mg/dL should be assessed with an ASCVD calculator; optimization of lifestyle is recommended for patients at low ASCVD risk (<5%); starting or maximizing statin therapy to reduce LDL is recommended for patients at medium (5% to 20%) or high risk for ASCVD; secondary causes must be ruled out for patients with triglyceride levels >500 mg/dL; icosapent ethyl may be given, but fibrates (eg, gemfibrozil, fenofibrate) should be considered; fibrates do not prevent cardiovascular event but are effective in preventing pancreatitis

Screening for colorectal cancer: colorectal cancer is the third leading cause of cancer-related death in the United States; more common in persons >65 yr of age; 10% of cases occur in patients <50 yr of age; <6% cases occurs in patients <45 yr of age; 25% of the population has never been screened for colon cancer; the USPFTS has stated that screening persons from 50 to 75 yr of age has substantial benefits; guidelines are applicable to asymptomatic persons at average risk; screening may be offered to persons >45 yr of age; the risk for persons <50 yr of age for developing colorectal cancer is one-fifth of that of persons >60 yr of age; screening for colorectal cancer in adults ≥50 yr of age is known to reduce deaths from colorectal cancer; a colonoscopy every 10 yr may prevent 58 colon cancers/1000 patients screened, which is the highest rate of prevention among testing modalities; the rate of prevention of computed tomography (CT) colonography is similar to that of the fecal immunochemical test (FIT)-DNA test (Cologuard) performed every yr, which is prevention of 54 colon cancers/1000 cases; addition of the FIT-DNA test to flexible sigmoidoscopy (flex-sig) every 5 yr produces a rate of prevention similar to colonoscopy; direct visualization test are slightly better than stool tests for prevention; however, there is less difference in life years gained between stool tests and direct visualization tests

Cost of screening: a colonoscopy every 10 yr costs $3000; flex-sig every 5 yr with annual fecal blood testing costs $560; annual fecal DNA testing has the same rate of prevention as flex-sig and costs $6000; CT colonography costs $4800, flex-sig alone costs $620, annual FIT testing costs $250; FIT-DNA may not prevent the highest number of cancers but is a viable approach for screening for colon cancer; fecal DNA testing every 3 yr is $1800

Readings

Adomaityte, Jurga, Farooq, Maria, Qayyum, Rehan. Effect of raloxifene therapy on venous thromboembolism in postmenopausal women: A meta-analysis. Thromb. haemost. 2008;99(02):338-342. doi:10.1160/TH07-07-0468. View Article; Bhatt, Deepak, Steg, Gabriel, Miller, Michael, et al. Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia. N Engl J Med. 2019;380(1):11-22. doi:10.1056/NEJMoa1812792. View Article; Bowman, Louise, MBBS, FRCP, Mafham, Marion, et al. ASCEND: A Study of Cardiovascular Events iN Diabetes: Characteristics of a randomized trial of aspirin and of omega-3 fatty acid supplementation in 15,480 people with diabetes. Am Heart J. 2018;198:135-144. doi:10.1016/j.ahj.2017.12.006. View Article; El-Beyrouty, Claudine, Buckler, Rebecca, Mitchell, Meghan, Phillips, Samantha, Groome, Sara. Pneumococcal vaccination-A literature review and practice guideline update. Pharmacotherapy. 2022;42(9):724-740. doi:10.1002/phar.2723. View Article; Hsiao A, Hansen J, Timbol J, et al. Incidence and estimated vaccine effectiveness against hospitalizations for all-cause pneumonia among older us adults who were vaccinated and not vaccinated with 13-valent pneumococcal conjugate vaccine. JAMA Netw Open. 2022;5(3):e221111. View Article; O'Byrne, Paul, MB, FRCP. Inhaled corticosteroids/formoterol as a reliever in mild asthma. Respirology. 2020;25(8):795-796. doi:10.1111/resp.13813. View Article; US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;326(12):1186-1191. doi:10.1001/jama.2021.14781. View Article; US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement [published correction appears in JAMA. 2021 Aug 24;326(8):773]. JAMA. 2021;325(19):1965-1977. doi:10.1001/jama.2021.6238. View Article; US Preventive Services Task Force, Owens DK, Davidson KW, et al. Medication Use to Reduce Risk of Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2019;322(9):857-867. doi:10.1001/jama.2019.11885. View Article.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Diamant's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Diamant was recorded at the 39th Annual Primary Care Summer Conference, held August 5-7, 2022, in San Diego, CA, and presented by Scripps Health. For information about upcoming CME activities from this presenter, please visit Scripps.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

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