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NSAIDs: Striving for Judicious Use

NSAIDs: Striving for Judicious Use

Every winter when cold and flu season hits, millions of people take non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen to ease the aches and pains associated with being sick. In addition, about 23 million Americans use over-the-counter NSAIDs every day. There were also close to 98 million prescriptions for NSAIDs filled last year, making them one of the most commonly prescribed medication classes in the United States. Addressing AEs Like all medications, NSAIDs can cause adverse events (AEs), particularly when they are used inappropriately. Both selective and nonselective NSAIDs can cause significant and even life-threatening events, including gastrointestinal, renal, and cardiovascular AEs. It’s important to counsel patients about appropriate use of NSAIDs. The FDA recommends using NSAIDs at the lowest effective dose for the shortest period of time required to provide therapeutic effect. The incidence of NSAID-related AEs increases significantly with concurrent use of multiple NSAID products and higher doses and longer duration of use. Many patients knowingly use prescription and OTC NSAIDs at the same time, increasing their risk of AEs. However, many more likely do so unknowingly because they’re unfamiliar with the term NSAID and don’t know which products are NSAIDs. Many patients are also unaware that some cold and pain medications contain NSAIDs that are combined with antihistamines, decongestants, or other analgesics, which can lead to using multiple NSAID products at the same time. A lack of patient awareness about NSAIDs—combined with the availability of OTC NSAID products—complicates their appropriate use. Ensuring Proper Use There are several steps physicians can take to ensure appropriate NSAID use. A thorough medication review at each patient visit, including...
Examining Physician Rx Drug Abuse

Examining Physician Rx Drug Abuse

Substance use is one of the most frequent causes of impairment among physicians, and some reports estimate that 10% to 15% of doctors will have a substance use disorder in their lifetime. “Substance-related impairment among physicians is a serious problem, with significant consequences for patient safety and public health,” says Lisa J. Merlo, PhD, MPE. “The rate of physician substance use is similar to that of the general population, but physicians are more likely to misuse prescription drugs. Understanding the reasons for prescription drug misuse may help us more successfully identify, treat, and monitor addicted physicians.” A key challenge to treating substance use disorders is that most physicians do not refer themselves for treatment, making it difficult to collect data on this issue. One strategy is to partner with physician health programs (PHPs) to recruit study participants. PHPs were established to ensure that distressed or impaired physicians are treated and monitored for the long term so that they can safely return to practice. “Studies have shown that nearly 80% of physicians who participate in PHPs remain substance free—with no relapse—at 5 years follow-up,” Dr. Merlo says. “Unfortunately, many doctors with substance use disorders have these problems for years before they seek help or are referred to a PHP.” Exploring the Issue Despite the impact of substance use among physicians, few analyses have looked at prescription drug misuse in this population. Studies have suggested that access to prescription medications may increase the risk of substance abuse among physicians. However, Dr. Merlo says that more information is needed to understand the reasons for prescription drug misuse among physicians and to develop...
Managing Inpatient Blood Glucose

Managing Inpatient Blood Glucose

Research indicates that hyperglycemia is a common finding among both medical and surgical patients, regardless of whether or not they have diabetes. When compared with patients who have normal glycemic levels, those with uncontrolled hyperglycemia have higher mortality and morbidity. These patients tend to have: • Delays in healing. • Poor immune responses. • Higher risks for cardiovascular events, inflammatory issues, and thrombosis. The extra care associated with these issues can increase healthcare costs unnecessarily. Need for Changes Many hospitals in the United States have protocols intended to implement intensive insulin therapy routinely in critically sick patients. However, based on new evidence, Amir Qaseem, MD, PhD, MHA, FACP, warns that physicians should not use intensive insulin therapy to strictly control blood glucose in hospitalized patients with or without diabetes. According to Dr. Qaseem, a potentially major harm in using intensive insulin therapy is that it can increase the risk of hypoglycemia. “This can lead to the same poor outcomes and adverse effects that we try to avoid with efforts to prevent or treat hyperglycemia,” he says. “Physicians should avoid aggressive glucose management and instead target levels of 140 mg/dL to 200 mg/dL when using insulin therapy.” Finding Balance To help clinicians find a balance between hyper­glycemia and hypoglycemia, Dr. Qaseem and colleagues at the American College of Physicians (ACP) reviewed recently published studies and developed recommendations on inpatient glycemic control. The document was published in the American Journal of Medical Quality. The first recommendation made by the ACP committee was that clinicians should avoid intensive insulin therapy to strictly control blood glucose or to normalize blood glucose in surgical...
Examining National Trends in Unscheduled Hospitalizations

Examining National Trends in Unscheduled Hospitalizations

Published data demonstrate that hospitalizations represent a significant portion of the annual expenditures for the United States healthcare system. A recent analysis by the RAND Corporation showed that emergency physicians are playing a greater role in healthcare beyond the services they provide in the ED. “Gaining a better understanding of recent changes in the sources of unscheduled ED admissions may provide opportunities to improve the quality and cost of inpatient care,” says Keith E. Kocher, MD, MPH. Analyzing the Effects In the journal Medical Care, Dr. Kocher and colleagues published an observational study examining the sources of unscheduled hospitalization over a 10-year period using data from the Nationwide Inpatient Sample. They also assessed implications for inpatient mortality and length of stay. Unscheduled hospitalizations were categorized as those related to transfers, direct admissions from outpatient providers, and the ED. Study results showed that about 82% of unscheduled admissions to the hospital came through the ED in 2009, representing a sharp increase from the 65% rate that was observed in 2000. Unscheduled hospitalizations arising from direct admissions and the ED changed substantially, while those due to transfers remained relatively stable. Direct admissions from clinics or doctors’ offices declined from about 31% to 14% of unscheduled admissions. Lower Mortality, Shorter Stays “In 2009, hospitalizations through the ED were associated with lower mortality overall when compared with direct admissions,” says Dr. Kocher. “These hospitalizations were also associated with a shorter hospital length of stay. These findings occurred despite a higher severity illness among patients and a greater chronic disease burden in 2009. It’s remarkable that patients admitted to the hospital from the ED...
PAD & Diabetes: Making the Connection

PAD & Diabetes: Making the Connection

According to recent estimates, more than 15 million Americans have peripheral arterial disease (PAD), a disease characterized by atherosclerotic occlusive disease of the lower extremities. “About 20% to 25% of patients with diabetes who are older than 50 has PAD,” says Peter Sheehan, MD. “Estimates are even higher in the Medicare population with diabetes. About 30% of diabetics aged 65 and older have PAD.” Of those with PAD, more than half are asymptomatic or have atypical symptoms, about one-third have claudication, and the remainder have more severe forms of the disease. Cardiovascular event rates in patients with PAD and diabetes are higher than those of their non-diabetic counterparts. Research has shown that PAD is a major risk factor for lower-extremity amputation, and it is also accompanied by a high likelihood for symptomatic cardiovascular and cerebrovascular disease. “Even for asymptomatic patients, PAD is a marker for systemic vascular disease involving coronary, cerebral, and renal vessels,” Dr. Sheehan says. “This increases the risk of myocardial infarction, stroke, and death.” He adds that diabetes and smoking are strong risk factors for PAD. Other well-known risk factors are advanced age, hypertension, and hyperlipidemia. Making the Diagnosis Diagnosing PAD is of clinical importance because it helps identify patients at high risk of heart attack or stroke, regardless of whether symptoms of PAD are present, and because it enables clinicians to elicit and treat symptoms. “Each patient with diabetes who has PAD will have varying symptoms and atherosclerotic disease,” says Dr. Sheehan. Accordingly, the American Diabetes Association recommends that patients have their feet checked regularly to assess for signs of foot complications and possible PAD...
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