AFP Journal Review August 1 & 15, 2008 Issues

1. AFP Journal ReviewAugust 1 & 15, 2008 Issues Marzena Slater, M.D. PGY-3 Emory Family Medicine

2. August 1st Spontaneous Vaginal Delivery Evaluation of Hematuria Patient Care: Mental Illness Skeletal Muscle Relaxants August 15th Update on the treatment of Tuberculosis Glucosamine Diagnosing GERD Treatment of Enuresis Articles Featured

3. August 1st Spontaneous Vaginal Delivery Evaluation of Hematuria Patient Care: Mental Illness Skeletal Muscle Relaxants August 15th Update on the treatment of Tuberculosis Glucosamine Diagnosing GERD Treatment of Enuresis Articles Featured

4. Patient Care: Mental Illness

5. Patient Care: Mental Illness • Family Physicians commonly care for patients with serious mental illness • Patients with psychotic and bipolar disorders have more co-morbid medical conditions and higher morality rates • Many medications prescribed for serious mental illness have significant metabolic and cardiovascular side effects • Many common medications can interact with antipsychotics, increasing the risk of cardiac arrhythmias and sudden death

6. Patient Care: Mental Illness • Causes of Poor Health: • Decreased access to health insurance/medical care • Less likely to receive preventative care (ex. Cancer screening, tobacco cessation counseling) • Less likely to receive Rx for acute problems • Lifestyle & behavioral factors • Medication adverse effects and interactions

7. Mental Illness- Antipsychotics

8. Mental Illness-Metabolic Derangement • Obesity and Weight Gain • Multifactorial • Second generation antipsychotics • Abilify(none)<Geodon<Risperidal<Zyprexa<Clozaril (10 lbs) in 10 weeks • Diabetes • Associated w/ 2nd generation antipsychotics • Clozaril & Zyprexa- greatest risk • Abilify & Geodon- lowest risk • Hyperlipidemia • 2nd Gen antipsychotics increase Triglycerides & total Cholesterol • Clozapine>Zyprexa>Seroquel>Abilify & Geodon

9. Prevention of Metabolic Changes • Exercise and weight management • All Pt- Physical activity counseling. • Overweight/obese- nutrition counseling • If Pt weight increase by > 5%- consider changing pt to different antipsychotic & refer to weight management program • Drug selection • Look at patient risk factors • Perform regular monitoring

10. Mental Illness: Drug Monitoring

11. CV Disease & QT prolongation • Use of antipsychotics is associated with 3 fold increase in risk of sudden cardiac death • 1st & 2nd degree antipsychotics have been ass. w/ QT prolongation • Medications known to cause QT prolongation should not be prescribed concurrently with antipsychotics

12. Drug Interactions • Second generation antipsychotics are metabolized via the Cytochrome p450 system • Medications that inhibit this system will lead to higher antipsychotic drug levels • Medications that induce this system will lead to lower antipsychotic drug levels • Always check for drug interactions when prescribing new drug in patients taking antipsychotics

13. Drug Interactions

14. Summary of Recommendations

15. Choosing a Skeletal Muscle Relaxant

16. Skeletal Muscle Relaxants • Widely used in Rx of musculoskeletal conditions • No good quality studies proving superiority to Tylenol or anti-inflammatory meds • Good for short term relief when NSAIDs or Tylenol not effective or not well tolerated • Adverse effects vary- all can cause dizziness and drowsiness. • Two categories: • Antispastic agents (ex baclofen)- for CP, MS • Antispasmotic agents- for musculoskeletal conditions- focus of this article

17. Skeletal Muscle Relaxants

18. Skeletal Muscle Relaxants

19. Skeletal Muscle Relaxants

20. Skeletal Muscle Relaxants

21. Summary of Recommendations

22. Skeletal Muscle Relaxants: Conclusions • Limited evidence for effectiveness- but there is some role in short term/acute use- preferably as an adjunct to NSAID/acetaminophen or as 1st line if these are contraindicated • Selection of agent should be based on: • Side effect profile • Abuse potential • Drug interactions • Cost • Reserve Soma and Valium as last line therapy- high potential for abuse

23. Update on Treatment of Tuberculosis

24. Update on Treatment of Tuberculosis • Why do we care? • 1/3 of the world’s population infected with latent TB- 11 million in U.S • Most cases in U.S. From foreign born persons from endemic countries • Prevalence greatest in economically disadvantaged and immunocompromised • Delays in detection & Rx allow for greater transmission of infection

25. Who do we screen?

26. Screening Tests Available • Tuberculin skin test (aka Mantoux, PPD) • Cheep • Current standard test • Poor sensitivity & low specificity • False Positives: • Non-TB Mycobacterium infection • Recent bacille Clamette-Guerin (BCG) shot • Subjective test interpretation • M. Tuberculosis Antigen specific interferon-gamma release assays • Greater specificity • Will not distinguish latent from active infection • May be falsely negative in HIV infection • Active infection • Dx by H&P, CXR, Sputum, +/- tissue biopsy

27. Latent TB • Lifetime risk of re-activation is 5-10% • HIV infected- reactivation 5-10% per year • Greatest risk within first 2 years of infection • RX: • Isoniazid • 9 months preferred (esp. HIV infected & kids <4yo) • 6 mo- in pt unable or unwilling to do a) • Baseline LFTs- Liver dz, alcoholics, HIV, pregnancy • Supplement w/ B6 in high risk pt* • Rifampin • 4 months Rx alternate to isoniazid • Not recommended for HIV patients • Isoniazid + Rifampin • 3 mo Rx- not 1st line therapy

28. Active TB • Combination Drug Rx prevents development of resistance • 2 Stages: • Intensive Phase- 4 drug regimen x 2 mo • Isoniazid, Rifampin, pyrazinamide, ethambutol • Continuation Phase • Isoniazid & a rifamycin x 4mo-7mo*

29. Side Effects of anti-TB drugs

30. Drug Resistance • Drug susceptibility of M tuberculosis should be preformed in all patients • 1.1% of cases in U.S are multi-drug resistant • Rx w/ 4-6 therapeutic agents recommended • 18-24 months of therapy • Average cost $250,000 (10X non-resistant) • Primary factors contributing to resistance: • Poor patient compliance w/ prev. regimens • Inappropriate drug selection or modifications • Virulent strain adaptation

31. HIV & TB • TB is an AIDS-defining illness in pt’s w/ HIV, the diagnosis of one requires testing for the other • HIV predisposes to extra-pulmonary and miliary TB and atypical presentations • Consider waiting 2 weeks after initiating TB rx before staring anti-retroviral rx*

32. TB & Pregnancy • Pregnancy itself not a significant risk factor for progression of latent to active TB • Treatment may be delayed in pregnancy and up to 3 months post partum in healthy women • Immunocompromised women should be treated in pregnancy: • Isoniazid or rifampin drugs of choice • Must get supplemental B6 (pyridoxine) if taking isoniazid

33. Summary of Recommendations

34. Evaluation and Rx of Enuresis

35. Enuresis main points • Definition= Repeated, spontaneous voiding of urine during deep sleep in child 5 years or older • 5-7 million children in U.S • Two types of Enuresis: • Primary- caused by disparity between bladder capacity, nocturnal urine production & failure of child to awaken in response to a full bladder • Secondary- less common. More likely due to medical, psychological or behavioral problem.

36. Types of Enuresis

37. Pathopysiology

38. Secondary Enuresis

39. Evaluation • Most children with enuresis only need: • Focused History -(o, p, s, t), ?daytime wetting, constipation, GU sx, neuro sx, FHx, psychosocial stressors, details or previous rx. • Physical- HEENT, spine, GU, Rectum. Look for signs of sexual abuse if 2’ enuresis • Labs: • UA, +/-Urine cx- help detect infection • Select tests if 2’ enuresis (glucose, BUN/Cr, TSH) • Imaging and urodynamic studies: • Only if significant daytime sx • H/o UTI’s • Suggestion of structural renal dz • Refractory cases

40. Treatment- General Concepts • Simple behavioral interventions are 1st line rx • Medications should be initiated in children 7 yo or older only if non-pharmacologic options fail • Children who do not respond to one or more measures may benefit from combination rx • Refer out if: • Persistent daytime wetting or abn voiding • Straining or poor stream • Genital abnormalities • Hx of recurrent UTIs

41. Non-pharmacologic options

42. Pharmacologic options

43. Summary of Recommendations

44. Question 1 A patient diagnosed with schizophrenia is prescribed olanzapine (Zyprexa) by his psychiatrist. 2 months after initiation of therapy, he has gained 4 % of his previous body weight. Which of the following is the best next step? a) Discontinue olanzapine b) Switch from olanzapine to clozapine (Cozaril) using slow cross titration. c) Enroll patient in weight management program d) Reassure the patient that the weight gain is common and that weight typically stabilizes after 3 months

45. Question 1 A patient diagnosed with schizophrenia is prescribed olanzapine (Zyprexa) by his psychiatrist. 2 months after initiation of therapy, he has gained 4 % of his previous body weight. Which of the following is the best next step? a) Discontinue olanzapine b) Switch from olanzapine to clozapine (Cozaril) using slow cross titration. c) Enroll patient in weight management program d) Reassure the patient that the weight gain is common and that weight typically stabilizes after 3 months

46. Question 2 Which of the following statements about skeletal muscle relaxants is/are correct? • Diazepam (Valium) is safe in pregnancy. • Chlorzoxazone (Parafon Forte) can cause urine to turn red or orange color. • Transient quadriplegia is a rare but potential adverse effect of carisoprodol (Soma). • Cyclobenzaprine (Flexeril) is the most studied skeletal muscle relaxant.

47. Question 2 Which of the following statements about skeletal muscle relaxants is/are correct? • Diazepam (Valium) is safe in pregnancy. • Chlorzoxazone (Parafon Forte) can cause urine to turn red or orange color. • Transient quadriplegia is a rare but potential adverse effect of carisoprodol (Soma). • Cyclobenzaprine (Flexeril) is the most studied skeletal muscle relaxant.

48. Question 3 Which one of the following patients should be screened for Mycobacterium tuberculosis infection? a) A 45 yo woman who immigrated to the U.S. from China 20 years ago b) A healthy 5 year old girl born in the U.S. c) A 50 yo man starting adalimumab (Humira) therapy for the treatment of rheumatoid arthritis d) A 16 yo boy living at home with his parents who have health insurance and a moderate income.

49. Question 3 Which one of the following patients should be screened for Mycobacterium tuberculosis infection? a) A 45 yo woman who immigrated to the U.S. from China 20 years ago b) A healthy 5 year old girl born in the U.S. c) A 50 yo man starting adalimumab (Humira) therapy for the treatment of rheumatoid arthritis d) A 16 yo boy living at home with his parents who have health insurance and a moderate income.

50. Question 4 Which of the following statements about the pharmacologic treatment of nocturnal enuresis is/are correct? a) Pharmacologic treatments are curative b) Pharmacologic treatments should not be initiated in children younger than 7 yo c) Behavioral treatments should be discontinued before initiating pharmacologic treatment. d) Pharmacologic treatment should be initiated only if nonpharmacologic treatment fails