AAFP Article Review

1. AAFP Article Review PriyaVasudevan MD PGY 3 Emory Family Medicine

2. Treatment of Allergic Rhinitis • Management of Obesity • Anemia in Children

3. Allergic Rhinitis • Allergic Rhinitis is a common respiratory illness that affects the quality of life, productivity and other co morbid conditions like asthma. • Mediated by Ig E antibody • Occurs after exposure to indoor/ outdoor allergens. • Symptoms include rhinorrhea, nasal congestion, obstruction, pruritis

4. Allergic Rhinitis • Treatment options includes • Intranasal corticosteroids • Oral anti histamines • Decongestants • Intranasal cromolyn • Leukotriene receptor antagonists

5. Intranasal Corticosteroids • Decreases the influx of inflammatory cells and inhibits the release of cytokines thereby reducing the inflammation of nasal mucosa. • Onset of action: 30 mins • Peak effect : takes several hours to days with maximum effectiveness takes up to two- four weeks.

6. Contd. • Many studies shows that intra nasal steroids are superior to oral/ intra nasal anti histamine alone. • RCT took quality of life as a measure and intra nasal steroids are better than oral anti histamines. • There is no evidence that one intra nasal steroid is superior than another.

7. Contd • Adverse effects with the intra nasal steroids are headache, throat irritation, epistaxis, stinging , burning sensation and nasal dryness. • Concerns about suppression of hypothalamo- pituitary axis and growth restriction , currently available products have not been shown to have such effect.

8. Oral AntiHistamines • First generation anti histamines include brompheniramine, chlorpheniramine, diphenhydramine. • Causes substantial adverse effects including fatigue and impaired mental status. • Second generation antihistamines have better adverse effect profile and cause less sedation with the exception of cetrizine.

9. Contd. • Shown to be effective at relieving the histamine mediated symptoms( sneezing, pruritis, rhinorrhea, ocular symptoms) • Less effective at treating nasal congestion compared to intra nasal steroids. • Onset of action is 15 to 30 mins and they are considered safe for children older than 6 months. • Very useful for mild symptoms requiring “as needed “ treatment.

10. Intranasal Antihistamine • Offer the advantage of delivering a higher concentration of medication to a specific targeted area. • Less adverse effects. • Azelastine is approved for ages 5 years and older. • Onset of action is 15 mins and lasts up to four hours. • Adverse effects include aftertaste, headache, epistaxis, nasal irritation. • Use is limited by their adverse effects and cost compared with oral antihistamines.

11. Decongestants • Oral and topical decongestants improve the nasal congestion by causing vasoconstriction and decreasing the inflammation. • Adverse effects are sneezing and nasal dryness. • Duration is usually not recommended for more than 3-5 days. • As they may develop rhinitis medicamentosa or rebound congestion.

12. Intranasal Cromolyn • Is available OTC • Acts by inhibiting the degranulation of mast cells. • Not a first line therapy because of decreased effectiveness at relieving symptoms and its inconvenient dosing schedule of 3-4 times daily.

13. Intranasal Anticholinergics • Ipratropium has been shown to provide relief only for excessive rhinorrhea. • Adverse effects include dryness of nasal mucosa and epistaxis. • Compliance issue since it needs to be administered 2-3 times daily.

14. Leukotriene Receptor Antagonist • Montelukast is FDA approved for treatment of allergic rhinitis • It is not effective as intranasal steroids or oral antihistamines • Should only be considered as second or third line of therapy.

15. Immunotherapy • Should be considered for patients with moderate to severe allergic rhinitis that is not responsive to usual treatments. • Consists of small amount of allergen extract given sublingually or Sq over the course of few years. • Greatest risk is anaphylaxis • Lack of FDA approval for home use and high cost

16. Nonpharmacologic Therapies • Acupuncture • Probiotics • Herbal Preparations • Nasal irrigation • Mite proof impermeable mattress and pillow covers.

21. Office-Based Strategies for the Management of Obesity • Obesity affects 33.8 % U.S adults. • 68 % are either overweight or obese • Obesity is a well-known risk factor for type 2 DM, HTN, HLD, pulmonary disease and heart disease. • Is associated with increased risk of colorectal cancer, endometrial cancer and renal cancer. • Higher rates of depression, bipolar disease and agoraphobia.

23. USPSTF recommends calculating BMI at least annually. • AAFP recommends screening for obesity and providing intensive counseling and behavioral interventions for adults with obesity. • One study found out that the patients were less likely to receive weight management advice from their PCP than from their partner, family, friends.

24. Possible Barriers • Lack of time • Lack of insurance reimbursement • Lack of support services( e.g., community based weight loss programs) • Lack of training and confidence among physicians in managing obesity. • Lack of practical tools to care for obese or overweight patients.

25. Common Strategies • Self-management or commercial weight loss programs • Recommending or prescribing medications for weight loss. • Recommending bariatric surgery • Assessing key habits and recommending lifestyle changes.

26. Self-Management and Commercial Weight-Loss Programs • Americans spend roughly $40 billion annually on commercial weight loss programs, such as weight watchers, LA weight Loss and Jenny Craig .. • Most popular diets are The Atkins, Zone, Ornish and Weight Watchers. • RCT compared these programs and found Atkins was modestly more effective

27. Contd. • All these programs appear to be safe. • Patients interested in these popular diets should be counseled that they are associated with modest but significant weight loss. • The amount of weight loss is strongly associated with the degree of adherence to the program.

28. Medications to Promote Weight Loss • Sibutramine and Orlistat are the only two medications currently approved for the long term treatment of obesity. • Sibutramine acts centrally to inhibit serotonin and nor epinephrine re uptake and increase satiety. • Sibutramine in combination with brief counseling resulted in mean weight loss of 16.66 lb after one year. • Blood pressure should be closely monitored.

29. Contd. • Orlistat ( Xenical) inactivates gastric and pancreatic lipases, preventing the absorption of fat through the GI tract. • Common adverse effects are bloating, flatulence and fatty or oily stools. • Orlistat alone resulted in a mean weight loss of 6.44 lb compared with placebo. • Orlistat is available OTC as “ alli “at 60 mg/dosage • Conclusion is that sibutramine and orlistat promote modest weight loss in combination with life style changes.

30. Bariatric Surgery • Surgical weight-loss procedures are classified as purely restrictive( limiting the volume of the stomach) and primarily malabsorbtive . • Restrictive procedures include laproscopic vertical banded gastroplasty, laparoscopic adjustable gastric banding, vertical sleeve gastrectomy. • Malabsorbtive procedure is Roux-en-Y gastric bypass.

31. A recent Cochrane review compared different bariatric procedures. • All were found to be effective in promoting weight loss than non surgical methods. • Gastric bypass was more effective than lap gastric banding. • Resolution of co morbidities with bariatric surgery is common.

32. Conclusion is bariatric surgery is an option for adults who have BMI of 40 kg per m2 or higher. • And for those adults who have a BMI of 35 kg per m2 or higher with significant obesity-related co morbidities( type 2 DM, HTN, OSA )

33. Medications • Medical causes of obesity should not be overlooked. • Many medications including beta blockers, corticosteroids, diabetes drug, atypical antipsychotics and valproic acid. • Among the DM drugs insulin and sulfonylurea's are associated with great gain.

34. Guidelines for the management of obesity have been available for many years, but the extent to which they have been adopted into primary care is unknown. • USPSTF has developed a useful framework known as the five A’s ( ask, advise, assess, assist, and arrange ) • Can be used for the delivery of obesity-related counseling.

37. Evaluation and Structured Counseling • Calculate the BMI • Ask the patient about their interest in achieving a healthier weight, whether or not he or she would like some help. • Ask about some common behaviors that may contribute for weight gain. • Next step is to advise the patient about impact of problem behaviors on weight • Assist them in meeting their goals. • Arrange for follow up to provide reinforcement over time.

38. The five A’s approach has important advantages over the others • Simple to deliver • Does not stigmatize the person who are obese or overweight • It is based on an existing paradigm that have been shown to be successful of counseling of other problem.

39. Anemia in Children • An estimated 20 % of American children will have anemia at some point in their childhood. • Screening is recommended only for high risk children. • Anemia is defined as Hb level of less than 5th percentile for age. • Causes vary by age.

44. Questions

45. 1. Which one of the following treatments is approved by the U.S. Food and Drug Administration for use in a four-year-old child with allergic rhinitis?  (check one) A. Intranasal beclomethasone (Beconase). B. Intranasal triamcinolone (Nasacort) C. Loratadine (Claritin). D. Azelastine (Astelin

46. 2. Which one of the following statements about nonpharmacologic therapy for allergic rhinitis is correct?  (check one) A. Immunotherapy should be considered for all patients after an initial trial of an oral second-generation antihistamine. B. Acupuncture is an effective treatment. C. Probiotics and herbal supplements are effective treatments. D. Sublingual immunotherapy is an effective option for selected adults.

47. 3. Which of the following statements about intranasal antihistamines are correct?  (check all that apply) A. They are approved for children as young as four years. B. They may cause nasal irritation or epistaxis. C. Onset takes two to four hours. D. They may cause a bitter aftertaste.

48. 4. Which one of the following statements about popular weight-loss diets is correct?  (check one) A. Low-fat diets result in greater weight loss than low-carbohydrate diets. B. The degree of adherence to the program correlates with the amount of weight lost. C. The Atkins diet is not recommended because of safety concerns. D. Commercial weight-loss programs are essential to self-managed weight loss.

49. 5. Which one of the following statements about pharmacologic and surgical management of obesity is correct?  (check one) A. Sibutramine (Meridia) and orlistat (Xenical) are approved by the U.S. Food and Drug Administration only for the short-term treatment of obesity. B. Bariatric surgery has no impact on morbidity or mortality. C. Bariatric surgery is recommended for patients with a body mass index of 30 kg per m2 or higher. D. Orlistat is available without a prescription in a 60-mg dose. E. Use of antiobesity medications appears to work better than intensive counseling in the long run.

50. 6. Which of the following medications are associated with weight gain?  (check all that apply) A. Metformin (Glucophage). B. Sulfonylureas. C. Alpha-glucosidase inhibitors. D. Atypical antipsychotics.