GuidelinesUpdate eBook 2012 FINAL

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Guidelines

Update

A collection o popular articles on updated guidelines.

www.physiciansweekly.com/guidelines

Read our top interview-based articles on

guidelines or managingMRSA, Alzheimers

disease, diabeticneuropaty and more!

Volume 3


2/15

visit www.physiciansweekly.com 3

Table o Contents14 A Look at Diagnosing Alzheimers Disease

Guy M. McKhana, MD

18 Expert Consensus Reached on ManagingHypertension in the Elderly Carl J. Pepine, MD, MACC

12 Guidelines or Diabetic Neuropathy John D. England, MD, FAAN

16 Guidelines on Assessing Adiposity Marc-Andre Cornier, MD

20 Guidelines or PAD: A Welcome Update Tom W. Rooke, MD, FACC

24 Welcome Guidelines or ManagingMRSA in Adults & Children Henry F. Chambers, MD

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For the rst time in nearly 3 decades, the clinicaldiagnostic criteria or Alzheimers disease anddementia have been revised, giving cliniciansmore advanced guidelines or moving orwardwith research on diagnosis and treatment.

required updating. Tree subgroups were established

to discuss the criteria, based on what would be thebiggest changes in the concepts o AD (able 1).

Tese included that AD starts years and perhaps

decades beore dementia develops and symptoms

are visible. Te result o this collaboration was the

establishment o new guidelines based on our

articles collectively called the National Institute

on Aging/Alzheimers Association Diagnostic

Guidelines or Alzheimers Disease. Te document

was published in the April 22, 2011 online edition

oAlzheimers & Dementia.

Te pre-symptomatic phase o AD includes people

who have laboratory evidence o the disease butno symptoms, explains Guy M. McKhann, MD,

who was a member o the group that updated

the diagnostic criteria. Te minimal cognitive

impairment (MCI) phase includes people with

memory problems who havent reached the stage

o being demented. Te nal phase includes those

who have dementia due to AD. Dening AD as a

spectrum that starts with early changes in the brain

will help acilitate clinicians ability to treat pre-

symptomatic AD in the uture, according to the

More than 27 years ago, the National Institute

o Neurological and Communicative

Disorders and Stroke and the Alzheimers and

Related Disorders Association (now the Alzheimers

Association) released diagnostic criteria or Alzheimers

disease (AD). At the time, AD was thought o only asa dementia. Te 1984 criteria stated that the ultimate

AD diagnosis was dependent on pathology. Since that

time, the basic concepts o AD have changed sig-

nicantly, and researchers have uncovered important

clues on the diagnosis o AD and dementia.

Time or a ChangeTe National Institute o Aging o the NIH and the

Alzheimers Association recently called a meeting

to discuss whether or not the diagnostic criteria

Guy M. McKhann, MD

Proessor o Neurology and Neuroscience

Center or Mind-Body Research

Johns Hopkins University

School o Medicine

A New Lookat Diagnosing

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4/15


should keep in mind that AD is an age-dependent

process. Te proportion o 65-year-olds who have

AD is probably less than 10%, but its probably 35%

to 40% among 90-year-olds.

A proportion o those who have AD also have other

neurological problems that can make diagnoses

challenging. As such, Dr. McKhann stresses that

providers become aware o these criteria and reer

patients on to AD specialists in order to ascertain

a rmer grip on the diagnosis. Te new criteria

capitalize on the latest scientic knowledge and

technological advances, Dr. McKhann says,

allowing or improved diagnosis and earlier

detection and treatment o AD. I you wait until

ull-blown dementia develops, its too late.

guideline authors. It is during the asymptomatic

phase that detrimental changes occur in the brain.

Individuals with evidence o these changes upon

testing or biomarker presence are at increased risk

or cognitive and behavioral impairment, as well as

progression to AD. Te use o these biomarkers

in diagnosing Alzheimers dementia and MCI also

appeared over the last 27 years, notes Dr. McKhann.

Several biomarker types have emerged since the last

criteria were released (able 2). Some biomarkers

are related to imaging, including those that show

evidence o structural change in the brain and

accumulation o components o the amyloid

plaquethe breakdown product that helps orm

AD, says Dr. McKhann. He eels that one o

the biggest breakthroughs in AD research in the

past decade has been the ability to image amyloid

in the brain with PE scans. Te other types o

biomarkers look or the presence o tau or amyloid

breakdown products in spinal uid.

Tere was a broad consensus among the work-

groups that additional research is needed to vali-

date the application o biomarkers in diagnosing

AD. Te guidelines propose using biomarkers in

AD and MCI due to AD as a research agenda only,

not as a current application in clinical settings.

While these biomarkers have been relatively well

established when utilized properly in rst-rate labs,

theyre not ready or general use because o stan-

dardization issues, adds Dr. McKhann. Te eldis changing rapidly, and the hope is biomarkers will

become more widely available and used in diag-

noses. With these advancements, the criteria will

likely need updating.

Making a DiagnosisTe most recent guidelines pay more attention to the

dierential diagnosis o AD, according to McKhann.

When deciphering AD rom vascular disease o the

brain or other neurodegenerative diseases, clinicians

Table 1 The 3 Stages o Alzheimers

1)Dementia Due to Alzheimers Disease Cognitive

and behavioral symptoms that impair an individuals

ability to unction in daily lie. The workgroup:

Emphasized the continuing need and importance to rule

out other causes o cognitive decline and o documenting

progressive decline over time.

Noted that the diagnosis o Alzheimers dementia may

not always have memory impairment as its most central

characteristic; a decline in other aspects o cognition

(eg, word-nding, vision/spatial issues, and impaired

reasoning, judgment, and problem solving) may be the

presenting or most prominent symptoms at rst.

Proposed that, or research purposes, diagnostic certainty

may be improved by incorporating certain biomarker mea-

sures; however, the useulness and reliability o these tests

in everyday medical practice still needs to be tested.

2)Mild Cognitive Impairment (MCI) Due toAlzheimers Disease Mild changes in memory

and thinking ability, enough to be noticed and

measured, but not impairment that compromises

everyday activities. The workgroup reports that:

This impairment increasingly can be measured in

research, and is gradually being recognized in medical

and specialty practice.

More work is needed to distinguish those with MCI who

will go onto develop Alzheimers dementia rom those who

will not.

Biomarkers, as they become validated, may help increase

diagnostic accuracy in research settings.

3)Preclinical Alzheimers Disease Changes that

may indicate the very earliest signs o disease.

The workgroup recommended:

No diagnostic criteria or this phase o the disease.

Developing approaches or data collection to see i a

preclinical stage o the disease can be dened so that

people who will develop Alzheimers dementia can be

distinguished rom those who will not.

Ascertaining measurements o biomarkers and neuroim-

aging tests to characterize brain changes that may bepredictive o Alzheimers disease. Developing new assess-

ments to delineate the very earliest and subtle clinical

signs o decline are also needed.

Source:Adapted rom:AlzheimersAssociation. Availableat: www.alz.org/documents_cus-tom/Alz_Assoc_diag_criteria_guidelines_press_release_041911.pd.

Table 2 Two Types o AlzheimersBiomarkers

The incorporation o biomarkers o underlying Alzhiemers

disease state and ormalization o dierent stages o the

disease are important advances in diagnosing Alzheimers.

The new criteria indicate that biomarkers be divided into

two major categories:

1)Biomarkers o beta-amyloid accumulation.

These are:

Abnormal retention o beta-amyloid identiying tracer

compounds on PET imaging.

Low levels o beta-amyloid 1-42 in cerebrospinal

fuid (CSF).

2)Biomarkers o neuronal degeneration or injury.

These are:

Elevated levels o the protein tau (both total and

phosphorylated tau) in CSF.

Decreased fuorodeoxyglucose 18F (FDG) uptake on

PET imaging in a specic pattern involving the brains

temporo-parietal cortex.

Atrophy on structural MRI in a specic topographic

pattern involving the brains medial, basal and lateral

temporal lobes, and medial and lateral parietal cortices.

Source:Adapted rom: Alzheimers Association. Available at: www.alz.org/documents_custom/Alz_Assoc_diag_criteria_guidelines_press_release_041911.pd.

Te eld is changing rapidly, and the hope isbiomarkers will become more widely available

and used in diagnoses.Guy M. McKhann, MD

Guy M. McKhann, MD, has indicated to Physicians Weeklythat he serves on a data saety monitoringboard or Merck; has worked as a consultant or the Dana Foundation and Merck; and has received grants orresearch aid rom the Dana Foundation, NIH, and NINDS. For more inormation on this article, includingreerences, visit www.physiciansweekly.com.

Additional Resources:Alzheimers Association. New Criteria and Guidelines or Alzheimers Disease Diagnosis.

Available at: www.alzheimersanddementia.org/content/ncg.

McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis o dementia due to Alzheimers disease: recommendations

rom the National Institute on Aging and the Alzheimers Association workgroup. Alzheimers & Dementia. 2011.

Available at: www.alzheimersanddementia.org/webles/images/journals/jalz/2_JALZ1252_proo.pd.

Albert MS, DeKosky ST, Dickson D, et al. The diagnosis o mild cognitive impairment due to Alzheimers disease:

recommendations rom the National Institute on Aging and Alzheimers Association workgroup.Alzheimers & Dementia. 2011.


Sperling RA, Aisen PS, Beckett LA, et al. Toward dening the preclinical stages o Alzheimers disease: recommendations

rom the National Institute on Aging and the Alzheimers Association workgroup. Alzheimers & Dementia. 2011.



5/15


ConsensusReached on

ManagingHypertensionin the ElderlyAn expert consensus statement oers recommendations or theappropriate management o hypertension in patients aged65 and older, emphasizing eective strategies to reduce bloodpressure in this difcult-to-treat population.

Hypertension aects the overwhelming majority

o Americans over the age o 65, but many o

these individuals are unaware o their elevated

blood pressure. Evidence suggests that even elderly

people with diagnosed hypertension do not have

their condition adequately controlled. In the May

2011Journal o the American College o Cardiology,

the American College o Cardiology and the

American Heart Association (ACC/AHA) released

the rst expert consensus document on hyperten-sion in the elderly. Many hypertension trials in the

past have excluded elderly patients, so this consensus

relies heavily on subgroups o recent trials and expert

opinion rather than data rom clinical trials done

only in the elderly, explains Carl J. Pepine, MD,

MACC, who co-chaired the writing committee that

created the document. Our hope is to provide phy-

sicians with systematic recommendations to lower

blood pressure (BP) in older adults and to remind

them o some specic issues relevant to the elderly.

Clinical Relevance & GoalsDr. Pepine says that there is limited clinical evidence

available on specic target BP goals and therapeu-

tic options or elderly patients with hypertension.Fortunately, recent data rom large clinical trials o

multiple elderly cohorts, including the Hyperten-

sion in the Very Elderly rial (HYVE), have sug-

gested that treatment o hypertension is benecial

among this older population, he says. While the

target BP in the elderly population has not yet been

validated, evidence supports the current recommen-

dation o achieving BP less than 140/90 mm Hg or

patients up to age 80. Between the ages o 80 and

85, a BP o less than 145/90 mm Hg is acceptable.

Pushing older patients to

lower treatment goals (eg,

less than 130/80 mm Hg) is not

suggested because this may lead to adverse eectsrom medications needed to reach these goals or

rom simply having low BP. Data supporting lower

specic BP goals, based on coexisting conditions or

the prevention and management o coronary artery

disease, are lacking in elderly cohorts.

Diagnostic DifcultiesDue to age and comorbidities among the elderly

with hypertension, t he management o hyperten-

sion or these i ndividuals is oten complex. Despite

Carl J. Pepine, MD, MACCProessor o Medicine, Division o

Cardiovascular Medicine

University o Florida College o Medicine


6/15


the presence o comorbid illnesses, there is strong

evidence that better control o BP will reduce risks

o secondary cardiovascular events. One condi-

tion oten unrecognized in the elderly population

is orthostatic hypotension, which occurs when BP

drops as individuals go rom a seated to standing

position, says Dr. Pepine. Our recommendation is

that, at least once, BP should be recorded in several

positions. Some elderly patients have orthostatic

hypertension in which BP rises to abnormal levels

when they go rom seated to standing positions.

Treatment OptionsAccording to the ACC/AHA guidelines, physicians

should consider liestyle modication (able) and

drug therapy when treating hypertension in elderly

patients. Liestyle modication has been shown to be

as efective in this population as in younger patients.

Tere is also strong clinical evidence that elderly

patients with hypertension benet greatly rom

pharmacologic BP reduction. HYVE documented

reduced adverse outcomes with antihypertensive

drugs in patients with hypertension aged 80 and

older. ACE inhibitors, -blockers, angiotensin recep-

tor blockers, diuretics, and calcium channel block-

ers can be considered or lowering BP and reducing

cardiovascular outcomes among the elderly (Figure).

When considering drug options or elderly

patients, the duration and severity o the hyperten-

sion and comorbid conditions should play a role in

treatment decisions, says Dr. Pepine. Medications

that treat hypertension and reduce risks or heart

disease and stroke should be considered. Initial

anti-hypertensive drugs should be administered at

the lowest dose and gradually increased depending

on BP response. Te average elderly patient takes

more than six prescription drugs daily, which may

ultimately interere with adherence. Dr. Pepine adds

that eorts to reduce dosing and pill burdens should

be encouraged whenever possible, and combination

drugs should be considered.

A Patient PopulationWorthy o Treatment

As society continues to age, more and more elderly

patients are expected to have hypertension. Clini-

cians should treat older patients a s they would treat

younger individuals, and make eorts to improve BP

control regardless o age, Dr. Pepine says. reating

older individualsespecially octogenarianswill

help to decrease mortality and improve quality o

lie or these people as they reach their golden years.

In cases in which there is uncertainty about the opti-

mal course o action, reerrals to specialists should

also be considered.

Clinicians should treat older patients as theywould treat younger individuals, and make

eorts to improve BP control regardless o age.Carl J. Pepine, MD, MACC

*For overall cardiac risk reduction, stop smoking. The eects o implementing these modications are dose and time dependent and could be higher in some individuals.

Abbreviations:BP, blood pressure; DASH, Dietary Approaches to Stop Hypertension. Source:Adapted rom: Aronow WS, et al.J Am Coll Cardiol. 2011;57:2037-2114.

Table Recommended Liestyle Modifcations

Modifcation

Weight reduction

Adopt DASH eating plan

Dietary sodium reduction

Physical activity

Moderation o

alcohol consumption

Recommendation

Maintain normal body weight (BMI, 18.5-24.9 kg/m 2)

Consume a diet rich in ruits, vegetables, and low-at dairy products

with a reduced content o saturated and total at

Reduce dietary sodium intake to no more than

100 mEq/L (2.4 g sodium or 6.0 g sodium chloride)

Engage in regular aerobic physical activity (eg, brisk walking)

at least 30 min/day most days o the week

Limit consumption to no more than 2 drinks/day in most men;

no more than 1 drink/day in women and lighter-weight people

Approximate Systolic BP

Reduction Range

5-20 mm Hg/10-kg weight loss

8-14 mm Hg

2-8 mm Hg

4-9 mm Hg

2-4 mm Hg

Optimize dosages or add additional drugs until goal blood

pressure is achieved. Refer to a clinical hypertension

specialist if unable to achieve control.

Majority will require at least 2

medications to reach goal if at

least 20 mm Hg above target.

Initial combinations should be

considered. The combination of

amlopidine with an RAS blocker

may be preferred to a diuretic

combination, though either is

acceptable.

Stage 1 Hypertension Stage 2 Hypertension

SBP 140-159 mm Hg

or DBP 90-99 mm Hg

SBP 160 mm Hg or

DBP 100 mm Hg

ACEI, ARB, CA, diuretic,

or combinationBB, CA

Compelling Indication

Heart failure

Post-myocardial

infarction

CAD or high CVD risk

Angina pectoris

Aortapathy/

aortic aneurysm

Diabetes

Chronic kidney

disease Recurrent stroke

prevention

Early dementia

Initial Therapy Options*

THIAZ, BB, ACEI, ARB,

CA, ALDO ANT

BB, ACEI, ALDO ANT, ARB

THIAZ, BB, ACEI, CA

BB, ARB, ACEI,

THIAZ, CA

ACEI, ARB, CA,

THIAZ, BB

ACEI, ARB,

THIAZ, ACEI, ARB, CA

Blood pressure control

Without Compelling Indications With Compelling Indications

Principles of Hypertension Treatment

Achieved values


7/15


New Guidelines orDiabeticNeuropathy

Te American Academy o Neurology has released newguidelines on the management o painul diabetic

neuropathy that provide evidence-based inormationon use o a range o treatment strategies.

T

he prevalence o neuropathy among those

with diabetes has been estimated to be as high

as 50%. Painul diabetic neuropathy (PDN),which tends to aect the eet and legs, has been esti-

mated to aect roughly 16% to 20% o the more

than 25 million people in the United States who are

living with diabetes. Te condition oten goes unre-

ported and even more are untreated, with an esti-

mated 40% o patients not receiving care or PDN.

A Need or GuidancePainul diabetic neuropathy is

a big problem or all healthcare providers who treat

patients with diabetes, says John D. England, MD,

FAAN. Tere are increasingly more drugs being

developed and brought to market that can be used

or treating diabetic neuropathy. For a busy practi-tioner, its oten difcult to keep up with all o the

new evidence and to decide what a rational, tiered

approach should be to treatment. Part o the issue is

the volume o literature on the topic. In 2007, when

members o the American Academy o Neurology

(AAN) elt there was a need to update guidelines

or the treatment o PDN, the process started with

more than 2,200 papers. O them, 463 were deemed

relevant and 79 were highly pertinent to the guide-

lines. Since then, many more studies have emerged.

John D. England, MD, FAAN

The Grace Benson Proessor and Head o

Neurology

Louisiana State University Health Sciences Center

School o Medicine

Fellow

American Academy o Neurology

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8/15


In the May 17, 2011 issue oNeurology, the AAN

published its rst evidence-based guidelines on use

o a range o pharmacologic and non-pharmaco-

logic treatments or diabetic neuropathy. Tere is

no cookbook approach to treatment or PDN,

explains Dr. England, who co-chaired the AAN panel

that developed the guidelines. We can, however,

use the scientic evidence in the literature and make

sure that it conorms to our clinical judgment and

patient preerences. What one patient may respond

to may be very dierent rom that o another. Te

evidence provides some guidance on how we should

treat this complication o diabetes. Dr. England

adds that it is important to explain to patients that it

is not common or patients to achieve complete pain

relie even though medications are available to help

relieve some o their pain.

Key RecommendationsPhysicians need to be particularly careul with pain

measurements because pain is a subjective com-

plaint, says Dr. England. Pain is measured with

standardized scales, but what level o pain relie

is actually experienced by patients is a subjective

response. Tat is why well-studied research popula-

tions are needed. We want to exclude any potential

conounding actors. Over the past couple decades,

the AAN has developed a robust system or classiy-

ing evidence rom the therapeutic trials that study

this patient population.

Using this system, Dr. England and colleagues rated

the level o evidence or several t herapeutic modali-

ties that can be used to treat patients with PDN.

It should be noted that many o these patients

have severe enough pain that they require multiple

modalities to help them, noted Dr. England. He

adds that most o the agents listed in able 1 reduce

pain by 30% to 50%, on average. Tereore, mix-

ing and matching agents and other therapies is oten

required to help patients eel as comortable as pos-

sible. In addition, several agents are still being used

to treat this population when there is either insu-

cient evidence to support or even evidence against

their use, says Dr. England. Physicians should

reer to the AAN guidelines to learn which drugs

have the best scientic evidence supporting their use

to treat PDN.

A Need or ChangeDr. England says special attention should be paid

to the medications indicated or PDN that have

level B recommendations. Unortunately, the

paucity o data makes it challenging or physicians

to truly know which therapeutic interventions are

better and the ideal candidates or each option, he

says. We need comparative eectiveness trials to

determine which drugs in the treatment o PDN

are superior.

Among other changes Dr. England would like to see

made in research is the selection o a single pain rat-

ing scale (able 2). Using such a scale in all trials

would enable investigators to compare trials against

each other with greater accuracy. Also, aside rom

a ew recent studies, most analyses only measure

pain relie. Tey should also measure quality o lie

and unction. Patients could have some pain relie

but still experience deteriorated quality o lie and

unction, depending on adverse events rom medica-

tions. We have come a long way in improving the

management o diabetic neuropathy, but we still

have a long way to go. Te only way that were going

to get better i s to und more research.

Physicians should reer to the AAN guidelinesto learn which drugs have the best scienticevidence supporting their use to treat PDN.

John D. England, MD, FAAN

Table 1 Summarizing Treatment Recommendations

Recommended Drug and Dose Not Recommended

Level A Pregabalin, 300600 mg/day

Level B Gabapentin, 9003600 mg/day

Sodium valproate, 5001200 mg/day

Venlaaxine, 75225 mg/day

Duloxetine, 60120 mg/dayAmitriptyline, 25100 mg/day

Dextromethorphan, 400 mg/day

Morphine sulphate, titrated to 120 mg/day

Tramadol, 210 mg/day

Oxycodone, mean 37 mg/day, max 120 mg/day

Capsaicin, 0.075% qid

Isosorbide dinitrate spray

Electrical stimulation, percutaneous nerve stimulation x 34 weeks

Oxcarbazepine

Lamotrigine

Lacosamide

ClonidinePentoxiylline

Mexiletine

Magnetic eld treatment

Low-intensity laser therapy

Reiki therapy

Source:Adapted rom: Bril V, et al. Neurology, 2011;76:1758-1765. Available at www.neurology.org/content/early/2011/04/08/WNL.0b013e3182166ebe.

Table 2 Recommendations orFuture Research A ormalized process or rating pain scales or use

in all clinical trials should be developed.

Clinical trials should be expanded to include eects on

quality o lie and physical unction when evaluating

ecacy o new interventions or painul diabetic neu-

ropathy (PDN); the measures should be standardized.

Future clinical trials should include head-to-

head comparisons o dierent medications and

combinations o medications.

Because PDN is a chronic disease, trials o longer

duration should be done.

Standard metrics or side eects to qualiy eect

sizes o interventions need to be developed.

Cost-eectiveness studies o dierent treatments

should be done.

The mechanism o action o electrical stimulation

is unknown; a better understanding o its role,

mode o application, and other aspects o its use

should be studied.

Source: Adapted rom: Medical Care Criteria Committee. Hepatitis C. New York StateDepartment o Health AIDS Institute. Available at: www.hivguidelines.org/clinical-guidelines.

John D. England, MD, FAAN, has indicated toPhysicians Weeklythat he serves on the speakers bureau or and hasreceived unding or travel or speaker honoraria rom Talecris Biotherapeutics and Teva Pharmaceutical Industries. Healso receives research support rom the NIH/NINDS, AstraZeneca, and Pfzer, and holds stock/stock options in Pfzerand Talecris Biotherapeutics. For more inormation on this article, including reerences, visit www.physiciansweekly.com.

Additional Resources:Bril V, England J, Franklin GM, et al. Evidence-based guideline: treatment o painul diabetic neuropathy : Report o the

American Academy o Neurology, the American Association o Neuromuscular and Electrodiagnostic Medicine, and the

American Academy o Physical Medicine and Rehabilitation. Neurology. 2011 Apr 11 [Epud ahead o print].

Available at: www.neurology.org/content/early/2011/04/08/WNL.0b013e3182166ebe.

Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic neuropathies: a statement by the American Diabetes Association.

Diabetes Care. 2005;28:956-962.

Gordois A, Scuham P, Shearer A, et al. The health care costs o diabetic peripheral neuropathy in the US.

Diabetes Care. 2003;26:1790-1795.


9/15


New Guidelines on

Assessing

AdiposityA scientic statement rom the American Heart Associationdiscusses challenges and issues associated with assessing adiposity.Recommendations are provided or identiying at-risk overweight

and obese patients.

The rate o obesity in the United States has reached

the epidemic level despite eorts by healthcare

providers and patients to improve health-related

behaviors and increased eorts to better understand

its pathophysiology. Assessment or excess adiposity

is o critical importance, says Marc-Andre Cornier,

MD. o address the issue o assessing adi-posity,

the American Heart Association (AHA) released a

scientic statement to help clinicians. Te statement,which was published in the November 1, 2011 issue

oCirculation, provides practical guidance or clinical

researchers who seek to identiy precise measurements

or their patients. It also provides recommendations

or clinicians who care or patients whose excess

weight is a clinical problem.

Beore clinicians can recommend treatment

options or talk to patients about obesity prevention,

they need to know whether a patient is obese, says

Marc-Andre Cornier, MD

Associate Proessor o Medicine, Division o

Endocrinology, Metabolism and Diabetes

University o Colorado School o Medicine,

Anschutz Medical Campus

Sta Endocrinologist, Department

o Medicine

Denver Health Medical Center

http://www.physiciansweekly.com/adiposity-guidelines/http://www.physiciansweekly.com/adiposity-guidelines/


10/15


Dr. Cornier, who was the lead author o the AHA

scientic statement. He adds that there are also new

Medicare guidelines or covering obesity treatment

that require clinicians to identiy whether or not

patients are obese. Medicare will cover provider

visits or weight loss counseling in patients who

screen positive or obesity.

Reviewing the MethodologiesHealthcare providers and systems are not regularly

assessing or excess adiposity with even the sim-

plest, least costly methods, says Dr. Cornier. Most

methods or assessing excess adiposity are not ready

or routine clinical use, he says. Measuring BMI

and waist circumerence is currently best to assess

adiposity. Tese are strategies all clinicians should

be practicing on a regular basis or patients. Other

newer, complex, and more expensive tools are cur-

rently available, but physicians need to do a better

job utilizing the simpler tools we currently have at

our disposal.

Most o the evidence in the literature on assessing

adiposity has been ocused on measuring BMI and

waist circumerence. Waist circumerence is a marker

o visceral at, which is a ssociated with at deposited

in the liver, muscle, heart, and other areas thought

to be associated with metabolically active at that

causes metabolic disease. Measuring or body at

composition is o growing importance, explains Dr.

Cornier (able 1). More and more studies show

that the percent o ones body that is made up rom

at is o ar more importance than their weight.

Fat distribution measurements are also impor-

tant because they can show clinicians where at is

deposited. Tis in turn enhances risk assessments

(able 2). While imaging tests like C and MRI

are ideal or assessing at distribution, both are

expensive and thereore not recommended or

clinical use in the AHA scientic statement. Dual-

energy X-ray absorptiometry, or DEXA, scanning

is commonly used or measuring bone density and

could be also used to measure body composition and

distribution, says Dr. Cornier. Unortunately, such

a strategy is expensive and may not provide moreinormation than a waist circumerence or BMI

measurement.

Skinold thickness is a another simple test that

can be used to assess adiposity, but it only looks

at one part o the body and ocuses only on

subcutaneous at, which has little or no asso-

ciation with metabolic or cardiovascular disease.

Hydrostatic weighing is another potential testing

option, but Dr. Cornier notes that it is difcult

to utilize this tool because it requires patients

to be put into a pool. Despite a relatively low

associated cost, ultrasound or assessing adiposity

has not been studied closely enough, and more

research is warranted. In addition to BMI and

waist circumerence measurements, utilizing blood

tests or various metabolic and cardiovascular

disorders is recommended, Dr. Cornier says.

Tis combination can provide much inormation

at little cost.

A Look Into the FutureDr. Cornier believes that near inrared interactance

and air displacement plethysmography could be

clinically relevant methods or assessing adiposity

in the near uture. Tese are strategies that

would not be too costly, he says. However,

bioelectric impedance may be the most practical

and inexpensive method. It has the potential to

improve the measurement o body composition and

may be a cheaper and simpler approach. Although

more research is needed, its easible that bioelectric

impedance may be ready or greater use in the next

5 to 10 years.

In the meantime, Dr. Cornier recommends that an

emphasis be placed on obesity as a serious societal

problem, both medically and nancially, that needs

to be controlled and prevented. Its important that

physicians learn how best to assess or excess adiposity

and know the associated risk actors. For now, most

patients should be assessed or adiposity using BMI

and waist circumerence measurements.

In addition to BMI and waist circumerencemeasurements, utilizing blood tests or various metabolic

and cardiovascular disorders is recommended.

Marc-Andre Cornier, MD

Clinical Use

++

+

+

+

+

+

+

+

Table 1 Potential Utility o Methodsor Assessing Body Composition

Method

Anthropometry

Skinold thickness

Ultrasound

Near-inrared interactance

Hydrostatic weighing

Air displacement plethysmography

DEXA

CT/MRI

Bioelectric impedance

Notes: ++, accepted method; +, uncommonly used method; and , not recommendedor clinical use.

Abbreviation:DEXA, dual-energy X-ray absorptiometry.

Source:Adapted rom: Cornier M, et al. Circulation. 2011;124:1996-2019.

Table 2 Potential Utility o Methodsor Assessing Body Fat Distribution

Method

Waist circumerence

Hip circumerence

Thigh circumerence

Neck circumerence

Ratios

Waist-to-hip

Waist-to-height

Waist-to-thigh

Imaging

CT

MRI

Notes: +++, widely accepted method; ++, accepted method; +, uncommonly usedmethod; and , not recommended or clinical use.

Source:Adapted rom: Cornier M, et al. Circulation. 2011;124:1996-2019.

Clinical Use

+++

+

+

+

++

+

+

Marc-Andre Cornier, MD, has indicated to Physicians Weeklythat he has or has had no nancial intereststo report. For more inormation on this article, including reerences, visit www.physiciansweekly.com.

Additional Resources:Cornier M, Desprs J, Davis N, et al. Assessing adiposity: a scientic statement rom the American Heart Association.

Circulation. 2011;124:1996-2019.

Strazzullo P, DElia L, Cairella G, et al. Excess body weight and incidence o stroke: meta-analysis o prospective studies with

2 million participants. Stroke. 2010;41:e418-e426.

Gruson E, Montaye M, Kee F, et al. Anthropometric assessment o abdominal obesity and coronary heart disease risk in men:

the PRIME study. Heart. 2010;96:136-140.

Jacobs E, Newton C, Wang Y, et al. Waist circumerence and all-cause mortality in a large US cohort.Arch Intern Med.

2010;170:1293-1301.

Blher M. The distinction o metabolically healthy rom unhealthy obese individuals. Curr Opin Lipidol. 2010;21:38-43.

Ibrahim M. Subcutaneous and visceral adipose tissue: structural and unctional dierences. Obes Rev. 2010;11:11-18.


11/15


Guidelines or PADA Welcome Update

Updated guidelines or the diagnosis and managemento peripheral arterial disease (PAD) include expandedcriteria or an earlier PAD diagnosis, increased eorts

or smoking cessation, and improved use o clot-preventingmedications and other interventions.

Peripheral arterial disease (PAD) is a commonand dangerous condition that aects millions

o Americans, especially those with a history

o diabetes or smoking. Despite eorts to increase

awareness in the medical community, the disease

remains largely underdiagnosed. For many patients,

PAD is asymptomatic and may not lead t o recogniz-

able symptoms. In turn, a diagnosis may be delayed.

I let untreated, PAD has been shown in published

research to be predictive o heart attack, stroke, leg

amputations, and death.

In 2005, the American College o Cardiology Foun-

dation (ACCF) and the American Heart Association

(AHA), along with collaborating societies, released

guidelines or the management o PAD. In 2011,

the ACCF/AHA updated these guidelines to reect

new data in the diagnosis and treatment o the con-

dition. Te 2011 guideline includes new inorma-

tion or diagnosing PAD, smoking cessation, the use

o antiplatelet therapy, and interventions or treating

severely ischemic limbs and abdominal aortic aneu-rysms (AAAs), says Tom W. Rooke, MD, FACC,

who chaired the committee that developed the 2011

guidelines. Te update can assist primary care clini-

cians, cardiologists, pulmonologists, interventional

radiologists, vascular surgeons, and vascular medi-

cine specialists in improving patient care.

Diagnosing PADTe 2011 ACCF/AHA guideline includes a recom-

mendation to lower the age at which ankle-brachial

Thom W. Rooke, MD, FACC

Krehbiel Proessor o Vascular Medicine

Mayo Clinic School o Medicine

lick here to view this article online.
http://www.physiciansweekly.com/peripheral-arterial-disease-guidelines/http://www.physiciansweekly.com/peripheral-arterial-disease-guidelines/


12/15


index (ABI) diagnostic testing should be perormed

in the practice setting. Previously, the recommen-

dation was or patients aged 70 or older to receive

an ABI, says Dr. Rooke. Tat threshold has been

lowered to age 65 or older based on mounting evi-

dence demonstrating that people in this age range

have a 20% chance o having either symptomatic or

asymptomatic PAD. Furthermore, ABI diagnostic

testing is now recommended or patients aged 50

and older i they have a history o diabetes or smok-

ing because they are considered at especially high

risk or PAD.

Quitting SmokingRecommendations or physicians to help people

with PAD quit smoking are strengthened in the

2011 ACCF/AHA guideline update (able 1). Doc-

tors are now recommended to consistently ask cur-

rent and ormer smokers about tobacco use at each

visit. In addition, physicians should be proactive

about oering support through counseling, phar-

macologic therapies, and ormal smoking cessation

programs. In addition to other health benets,getting patients to quit smoking can have a signi-

cant impact on outcomes in PAD, says Dr. Rooke.

Smoking cessation can lower risks o disease-related

comorbidities, including heart attack, stroke, and

lower limb amputation.

Other ImportantRecommendationsIn addition to changes in diagnosing PAD and

increasing smoking cessation eorts, the 2011

guideline update broadens the indications or using

antiplatelet therapies and antithrombotic drugs

(able 2). Te use o therapies that prevent clotting

is important when treating patients with PAD, Dr.

Rooke says. Several new Class IIa and IIb recom-

mendations were made in the update, while other

recommendations rom the 2005 guidelines were

modied to reect new evidence that has emerged

in recent years.

Leg artery angioplasty is indicated as a rst-line

treatment or certain individuals with severe PAD

who may require amputation. Balloon angioplasty,

however, is not an ideal treatment or all patients

with PAD. Te guidelines now recommend angio-

plasty as the initial procedure to improve distal

blood ow or patients with limb-threatening lower

extremity ischemia and an estimated lie expectancy

o 2 years or less. Bypass surgery is recommended or

these patients i they have an estimated lie expec-

tancy o more than 2 years.

New recommendations were also added or manag-ing AAAs. Open or endovascular repair o inrarenal

AAAs and common iliac aneurysms is now indicated

in patients who are good surgical candidates. Open

aneurysm repair can be used in good surgical can-

didates who cannot comply with the periodic long-

term surveillance that is required ater endovascular

repair. However, it is unknown whether or not

patients with inrarenal aortic aneurysms who are

at high surgical or anesthetic risk will benet rom

endovascular repair.

Looking ForwardWhen PAD is undetected and poorly managed, it

is among the most costly cardiovascular diseases.

We still have a long way to go in order to improve

the management o PAD, says Dr. Rooke. Te

2011 ACCF/AHA guideline update can serve as

a roadmap to the most appropriate practices and

interventions based on evidence-based science, but

opportunities remain to urther our knowledge and

eorts or prevention and earlier, lie-saving inter-

ventions. Unti l more data emer ge, promoting use

o these guidelines in hospitals and healthcare sys-

tems may reduce the burden o PAD and improve

clinical outcomes associated with the disease.

Table 1 Smoking Cessation

Recommendation

Patients who are smokers or ormer smokers should be asked about status o tobacco use

at every visit.

Patients should be assisted with counseling and developing a plan or quitting that may include

pharmacotherapy and/or reerral to a smoking cessation program.

Individuals with lower extremity PAD who smoke cigarettes or use other orms o tobacco should be advised

by each o their clinicians to stop smoking and oered behavioral and pharmacologic treatment.

In the absence o contraindication or other compelling clinical indication, one or more o the ollowing

pharmacologic therapies should be oered: varenicline, bupropion, or nicotine replacement therapy.

Abbreviations: PAD, peripheral artery disease. Source: Adapted rom: Rooke TW, et al.J Am Coll Cardiol.2011;58:2020-2045.

Level o Evidence

A

A

C

A

Table 2 Antiplatelet & Antithrombotic Drugs

Recommendation

Class I

Antiplatelet therapy is indicated to reduce the risk o MI, stroke, and vascular death in individuals with

symptomatic atherosclerotic lower extremity PAD, including those with intermittent claudication or critical

limb ischemia, prior lower extremity revascularization (endovascular or surgical), or prior amputation or

lower extremity ischemia.

Aspirin, typically in daily doses o 75 to 325 mg, is recommended as sae and eective antiplatelet therapy

to reduce the risk o MI, stroke, or vascular death in individuals with symptomatic atherosclerotic lower

extremity PAD, including those with intermittent claudication or critical limb ischemia, prior lower extremity

revascularization (endovascular or surgical), or prior amputation or lower extremity ischemia).

Clopidogrel (75 mg per day) is recommended as a sae and eective alternative antiplatelet therapy

to aspirin to reduce the risk o MI, ischemic stroke, or vascular death in individuals with symptomatic

atherosclerotic lower extremity PAD, including those with intermittent claudication or critical limb

ischemia, prior lower extremity revascularization (endovascular or surgical), or prior amputation or

lower extremity ischemia.

Class IIa

Antiplatelet therapy can be useul to reduce the risk o MI, stroke, or vascular death in asymptomatic

individuals with an ABI less than or equal to 0.90.

Class IIb

The useulness o antiplatelet therapy to reduce the risk o MI, stroke, or vascular death in asymptomatic

individuals with borderline abnormal ABI, dened as 0.91 to 0.99, is not well established.

The combination o aspirin and clopidogrel may be considered to reduce the risk o cardiovascular events

in patients with symptomatic atherosclerotic lower extremity PAD, including those with intermittent

claudication or critical limb ischemia, prior lower extremity revascularization (endovascular or surgical),

or prior amputation or lower extremity ischemia, and those who are not at increased risk o bleeding and

who are at high perceived cardiovascular risk.

Class III: No beneft

In the absence o any other proven indication or wararin, its addition to antiplatelet therapy to reduce the

risk o adverse cardiovascular ischemic events in individuals with atherosclerotic lower extremity PAD is o

no benet and is potentially harmul due to increased risk o major bleeding.

Abbreviations:ABI, ankle-brachial index; MI, myocardial inarction; PAD, peripheral artery disease. Source:Adapted rom: Rooke TW, et al.J Am Coll Cardiol. 2011;58:2020-2045.

Level o Evidence

A

B

B

C

A

B

B

Tom W. Rooke, MD, FACC, has indicated to Physicians Weeklythat he has or has had no nancial intereststo report. For more inormation on this article, including reerences, visit www.physiciansweekly.com.


13/15


Clinicians are oten challenged with managing MRSAinections, but the Inectious Diseases Society o Americahas released new guidelines that provide a ramework tohelp determine how to evaluate and treat individuals withuncomplicated and invasive inections caused by MRSA.

Welcome Guidelines

or Managing MRSAAdults & Childrenin

MRSA has been well documented as a sig-

nicant cause o both healthcareassociated

and communityassociated inections. It is

the predominant cause o skin inections among

patients presenting to the emergency room and can

also cause more serious, invasive inections, which

account or about 18,000 deaths each year in the

United States. MRSA has an enormous clinical and

economic impact, explains Henry F. Chambers,

MD. Many clinicians oten have difculties when

managing these inections. When these patients are

not properly managed, the results can be severe. Poor

management can also promote antibiotic resistance,

which is ast becoming a growing concern among

clinicians.

A Framework or CliniciansIn the February 1, 2011 issue oClinical InectiousDiseases, an expert panel o the Inectious Diseases

Society o America (IDSA) released its rst evi-

dence-based, consensus guidelines on the treatment

o MRSA inections. Te primary objective o the

guidelines was to provide recommendations on the

management o some o the most common clinical

syndromes encountered by adult and pediatric cli-

nicians who care or patients with these inections.

Te IDSA expert panel addressed issues relating to

the use o vancomycin therapy in the treatment o

Henry F. Chambers, MD

Proessor o Medicine

Chie, Division o Inectious Diseases

San Francisco General Hospital

Director, Inectious Diseases Fellowship Training

Program

University o Caliornia, San Francisco

http://www.physiciansweekly.com/welcome-guidelines-for-managing-mrsa-in-adults-children/http://www.physiciansweekly.com/welcome-guidelines-for-managing-mrsa-in-adults-children/


14/15


MRSA inections, including dosing and monitor-

ing, current limitations o susceptibility testing, and

the use o alternate therapies or those patients with

vancomycin treatment ailure and inection due to

strains with reduced susceptibility to the drug.

Te guidelines provide a ramework to help clini-

cians determine the most appropriate means to

evaluate and treat patients with uncomplicated and

invasive inections caused by MRSA, explains Dr.

Chambers, who co-chaired the panel that developed

the guidelines. Tey discuss the management o a

variety o clinical syndromes associated with MRSA

disease, including skin and sot tissue inections

(SSIs), bacteremia and endocarditis, pneumonia,

bone and joint inections, and central nervous

system inections. Tese recommendations are pro-

vided in addition to those on the appropriate use

o vancomycin. Te guidelines have been endorsed

by the Pediatric Inectious Diseases Society, the

American College o Emergency Physicians, and the

American Academy o Pediatrics.

Key RecommendationsTe IDSA guidelines oer primarily expert opinion

on the management o MRSA because that is oten

the only currently available inormation. Te guide-

lines are designed to be a living document, meaning

they will evolve as new inormation and antibiotics

become available, says Dr. Chambers. He adds that

some o the key recommendations include guidance

on when to use antimicrobial therapy ater incision

and drainage resulting rom community-associated

MRSA (able 1). Incision and drainage alone is

likely adequate or most simple abscesses or boils,

and antibiotic therapy is not needed. Antibiotic

therapy is, however, recommended or other specic

situations in the guidelines.

Te management o all MRSA inections should

include identication, elimination, and/or debride-

ment o the primary source and other sites o inec-

tion when possible. Tis includes cases in which there

is drainage o abscesses; removal o central venous

catheters, prosthetic devices or other implants; and

debridement o osteomyelitis. Te guidelines also

indicate that education on personal hygiene and

appropriate wound care is recommended or all

patients with SSIs. Patients should be instructed to

keep drained wounds covered with clean, dry ban-

dages and maintain good personal hygiene, particu-

larly ater touching inected skin. Patients should

also be educated to avoid reusing or sharing personal

items that have contacted inected skin. Te guide-lines also list key perormance measures in managing

MRSA inections that all clinicians should ollow,

Dr. Chambers says (able 2). Within these per-

ormance measures is guidance on the appropriate

dosing o vancomycin as well as eorts that should

be taken to promote good clinical practices.

Looking AheadEach section o the IDSA guidelines begins with a

specic clinical question and is ollowed by recom-

mendations as well as summaries o the most rel-

evant evidence that support the recommendations.

Te intent was to create a roadmap or clinicians to

ollow and the rationale or why these recommenda-

tions were made, says Dr. Chambers. However,

while the guidelines provide good practice recom-

mendations to guide clinicians, we still have knowl-

edge gaps to address. For example, were hoping

to learn more about the optimal management and

duration o therapy or osteomyelitis and SSIs,

among other MRSA inections, and which, among

several alternatives, are the most eective regimens.

Tere is much more to be learned so that we can

optimize the management o MRSA inections. Te

current guidelines will hopeully serve as a bridge to

covering knowledge gaps in the uture.

MRSA has an enormous clinical andeconomic impact. Many clinicians oten havedifculties when managing these inections.

Henry F. Chambers, MD

Table 1 Using Antimicrobial TherapyAter Incision & DrainageThe ollowing items identiy when the use o antimicrobial

therapy ater incision and drainage that results rom

community-associated MRSA is recommended:

Severeorextensivedisease(eg,involvingmultiple

sites o inection) or rapid progression in presence oassociated cellulitis.

Signsandsymptomsofsystemicillness.

Associatedcomorbiditiesorimmunosuppression

(diabetes mellitus, HIV inection/AIDS, neoplasm).

Extremesofage.

Abscessinareadifculttodraincompletely

(eg, ace, hand, and genitalia).

Associatedsepticphlebitis.

Lackofresponsetoincisionanddrainagealone.

Source:Liu C, et al. Clin Infect Dis. 2011;52:285-322.

Table 2 5 Key PerormanceMeasures in Managing MRSA

The management o all MRSA inections

should include identication, elimination and/

or debridement o the primary source and other

sites o inection when possible (eg, drainage o

abscesses, removal o central venous catheters,

and debridement o osteomyelitis).

In patients with MRSA bacteremia, ollow-up

blood cultures 2-4 days ater initial positive cul-

tures and as needed thereater are recommended

to document clearance o bacteremia.

To optimize serum trough concentrations in adult

patients, vancomycin should be dosed according

to actual body weight (15-20 mg/kg/dose every

8-12 hours), not to exceed 2 g per dose.

Troughmonitoringisrecommendedtoachieve

target concentrations o 15-20 g/mL inpatients with serious MRSA inections and

to ensure target concentrations in those who

are morbidly obese, have renal dysunction,

or have fuctuating volumes o distribution.

Theefcacyandsafetyoftargetinghigher

trough concentrations in children requires ad-

ditional study but should be considered in those

with severe sepsis or persistent bacteremia.

When an alternative to vancomycin is being con-

sidered or use, in vitrosusceptibility should be

conrmed and documented in the medical record.

For MSSA inections, a -lactam antibiotic is thedrug o choice in the absence o allergy.

Source:Liu C, et al. Clin Infect Dis. 2011;52:285-322.

Henry F. Chambers, MD, has indicated to Physicians Weeklythat he has received grant support rom Pfzer andhas consulted or Pfzer, Astellas, and Ortho-McNeil. For more inormation on this article, including reerences,visit www.physiciansweekly.com.

Additional Resources:

Liu C, Bayer A, Cosgrove SE, et al . Clinical practice guidelines by the Inectious Diseases Society o America or thetreatment o methicillin-resistant Staphylococcus Aureus inections in adults and children. Clin Infect Dis. 2011;52:285-322.

Available at:http://cid.oxordjournals.org/content/early/2011/01/04/cid.ciq146.ull

Calee DP, Salgado CD, Classen D, et al. Strategies to prevent transmission o methicillin-resistantStaphylococcus aureus

in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S62-S80.

Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillin-resistant Staphylococcus aureusinections in the United States.

JAMA. 2007;298:1763-1771.

Rybak MJ, Lomaestro BM, Rotschaer JC, et al. Vancomycin therapeutic guidelines: a summary o consensus

recommendations rom the Inectious Diseases Society o America, the American Society o Health-System Pharmacists,

and the Society o Inectious Diseases Pharmacists. Clin Infect Dis.2009;49:325-327.


15/15

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GuidelinesUpdate eBook 2012 FINAL

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