Transcript 1 - RCRMC Family Medicine Residency

Restless leg, Cardiology
Which of the following agents is
associated with exacerbations of
restless legs syndrome (RLS)?
A) Diphenhydramine
B) Iron
C) Zolpidem
D) Gabapentin
Answer
• A) Diphenhydramine
Diagnostic criteria for RLS
include:
A) Urge to move legs during
periods of inactivity
B) Symptoms that may be
relieved by movement
C) Symptoms that occur or
worsen exclusively during
evening or night
D) All the above
Answer
• D) All the above
Pathophysiology
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dopaminergic dysfunction
related to decreased iron concentrations in substantia nigra
Common descriptions of RLS: “creepy crawly” sensation (eg, sensation of worms
crawling out of feet or ankles)
sensation of running water
often difficult for patients to describe sensations
Diagnostic criteria: urge to move limbs, accompanied by uncomfortable or unpleasant
sensations
urge to move begins during periods of inactivity
symptoms may be relieved by movement
symptoms occur exclusively or worsen during evening or nigh
Symptoms described as most troublesome by patients:
disruption of sleep
uncomfortable feeling
inability to stay still
Pain
Jerking
daytime fatigue
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Differential diagnosis
attention-deficit/hyperactivity disorder
agitated depression
essential tremor
Nocturnal leg cramps
Radiculopathy
peripheral neuropathy (starts at toes, with sensation often described as burning)
arthritic disease (occurs more often with weight bearing)
vascular disease
Exacerbations: can involve other parts of body (eg, arms)
always occurs in legs first
often exacerbated by levodopa and carbidopa (eg, Parcopa, Sinemet-10/100, Sinemet-25/100)
Laboratory tests: check serum ferritin level
iron saturation <20% considered abnormal
check metabolic panel and creatinine
Common clinical features: positive family history
response to dopaminergic therapy
periodic leg movements in sleep (PLMS) often noticed by bed partner in 50% of RLS patients
movements occur frequently (eg, every 40 sec)
patients often prefer sleeping with feet uncovered
symptoms generally do not respond to typical sleep hygiene (eg, refraining from watching television
before bedtime)
Nonpharmacologic strategies
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physical activity
Avoid caffeine and alcohol
stimulate legs
traveling on long flights —select aisle seat
occupy mind with, eg, food, computer
games, or movie
Choose the correct statement
about levodopa.
A) Onset slow
B) Best choice for intermittent
usage when RLS symptoms
occur occasionally
C) No risk for augmentation
D) Long duration of action
Answer
• B) Best choice for intermittent usage when
RLS symptoms occur occasionally
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Pharmacotherapy
dopaminergic agents (eg, levodopa, dopamine agonists)
anticonvulsants (eg, gabapentin, carbamazepine)
Opioids
sedative-hypnotic agents (eg, clonazepam [Klonopin])
supplement iron to bring saturation to >20% (vitamin C may improve absorption; consider side effects of iron)
Ropinirole (Requip); pramipexole (Mirapex; use lower doses than those used for Parkinson disease)
levodopa —fast onset; best choice for intermittent usage when symptoms occur occasionally
dopamine agonist recommended for daily symptoms
Other drawbacks of dopaminergic agents: augmentation— exacerbation and increased intensity of symptoms
spread of symptoms to arms
associated with levodopa (>200 mg/day) and carbidopa
effects less dramatic when medication stopped
rebound —symptoms occur early in morning
occurs with use of levodopa and carbidopa due to short action
side effects—include increased gambling or sexual urges
Gabapentin: start with 100 mg/day (recommended maximum dose 300 mg/day)
side effects include dizziness
Carbamazepine: monitoring levels not required
secondor third-line therapy for patients with neuropathy
Sedative-hypnotic agents: clonazepam may be less addictive than other agents
Zolpidem
use for RLS off Pharmacotherapy: label (more data needed)
no evidence of augmentation
patients may require higher doses
Opioids: third-line agents
tramadol recommended over hydrocodone for long-term us
RLS is a:
A) Neurodegenerative disorder
B) Physical condition
C) Mental condition
D) Vascular disease
Answer
• B) Physical condition
Children and RLS
• “growing pains” may be manifestation of
RLS
• trials evaluating potential pharmacologic
treatments under way
• check family history
• benzodiazepines, anticonvulsants, and
opioids prescribed for children with other
conditions, but levodopa should be used
with caution
• Summary of RLS: not neurodegenerative
disorder; physical rather than mental
condition
Patients with _______ have
muscle aches or weakness
without elevations in creatinine
kinase (CK).
A) Myalgia
B) Myositis
C) Rhabdomyolysis
D) All the above
Answer
• A) Myalgia
Definitions
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myalgia—ache or weakness without elevation of creatine kinase (CK)
myositis —ache or weakness with elevation of CK
rhabdomyolysis —muscle symptoms with marked elevation of CK (>10 times normal) and elevated
serum creatinine
Incidence of myalgias: higher in clinics than in trials, possibly due to increased direct-to-consumer
advertising of medications, voluntary nature of Food and Drug Administration (FDA) Adverse Event
Reporting System, and exclusion from clinical trials of patients with myalgias, extremes of age or
lifestyle, or use of drugs that could cause myalgias
study —looked at 7900 patients on high-dose statin for 3 mo, or with decreased dose or
discontinuation of statin in last 3 mo
medications included atorvastatin (Lipitor; 40-80 mg/day), fluvastatin (extended-release; 80 mg/day),
pravastatin (40 mg/day), or simvastatin (Zocor; 40-80 mg/day)
10% had muscle symptoms
incidence highest (20%) with simvastatin and lowest with fluvastatin
60% had widespread pain
most patients had pain in thighs and calves
25% had tendonitis
27% regarded pain as minor distraction
26% reported that pain interfered with major exertion, and 20% with minor exertion
20% of patients discontinued therapy
17% wanted reduced dose
myalgia generally occurred within first or second month (time of onset may be affected by other
medications that increase plasma levels
Which of the following statins
appears least associated with high
plasma levels due to high firstpass metabolism?
A) Simvastatin
B) Atorvastatin
C) Fluvastatin
D) Pravastatin
Answer
• C) Fluvastatin
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Risk factors for myalgias
alcohol use
heavy exercise
primary muscle disease
increased statin levels— use of high doses
low body mass index
drug interactions (eg, cytochrome P450
3A4 inhibitors)
verapamil, diltiazem, SSRIs, amiodarone, and colchicine tend to increase plasma levels (especially in
older patients, who may have altered kidney or liver function)
Pharmacogenomics: SLCO1B1 gene —encodes for organic transporter that brings statin to liver and
enhances uptake
deficiency in transporter results in higher plasma levels of statin and higher risk for complications
Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) —
12,000 patients in United Kingdom randomized to 20 mg or 80 mg of simvastatin after myocardial
infarction (MI)
isolated 120 patients who had myalgic complaints and elevations of CK
genome-wide scanning found C allele defect associated with 5- to 6-fold higher risk
patients with more complaints of myalgia had less reduction in cholesterol due to low uptake of drug
Management: no recommendation for routine monitoring of CK before therapy (consider in higherrisk patients [eg, patients who exercise heavily])
change statin or statin dose
fluvastatin associated with high first-pass metabolism (ie, less likely to result in high plasma levels)
ezetimibe (Zetia) and colesevelam expensive, with modest benefits
niacin may be beneficial
Alternative statin dosing
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based on small studies
Rosuvastatin (Crestor) —tolerability of 80% and lipid reduction of 29% seen with 5 to 20 mg/wk
similar results seen in other studies with 2.5 to 20.0 mg/wk, or dosing every other day (average dose
5 mg)
studies—1) looked at patients on ezetimibe (10 mg/day) for few months, followed by addition of
atorvastatin (10 mg twice weekly) for 3 mo
saw good tolerability and reduction in low-density lipoprotein (LDL)
2) looked at rosuvastatin (5 or 10 mg twice weekly) and saw reasonable LDL
Reduction
atorvastatin and rosuvastatin (drugs with long half-lives) could potentially be used every other day,
or 1 to 2 times/wk with reasonable reductions in LDL
3) looked at patients with previous coronary disease and myalgia on different statins
average LDL 175 mg/dL; after 3 mo, 16% LDL reduction seen with ezetimibe (10 mg/day), 33%
with fluvastatin (extended release; 80 mg/day), and greater reduction seen with combination of both
agents
myalgia complaints highest with ezetimibe, and lower with combination therapy
small number of patients discontinued therapy
4) small studies of ezetimibe and colesevelam saw 42% reduction in LDL
5) niacin (homeopathic dose, 500 mg; therapeutic dose, 2-3 g) shown to reduce LDL by 5% to 25%;
plant
stanols can be used
Xuezhikang
• study in China in 4800 patients with previous MI saw
significant reduction in event rates
• supplement combines other substances (eg, plant stanols)
with red yeast rice (fermented form of mold)
• active ingredient (monacolin K) same as that of lovastatin
• 4800 mg equal to 10 mg of lovastatin; concerns raised by
questionable manufacturing standards and lack of approval
by FDA
• available in China, but not in United States
• tolerability appears similar to that of statins; some cases of
renal failure reported
Statins with long half-lives (eg,
atorvastatin, rosuvastatin) could
potentially be used every other
day or 1 to 2 times weekly, with
reasonable reductions in lowdensity lipoprotein.
A) True
B) False
Answer
• A) True
Red yeast rice
A) Active ingredient (monacolin K) same as
that of lovastatin
B) Absorption increased by vitamin C;
associated with marked CK elevations
C) Blood levels shown to be reduced by
pravastatin; data inconclusive
D) Immediate-release form generally
associated with more side effects and
hepatotoxicity than extended-release form
Answer
• A) Active ingredient (monacolin K) same
as that of lovastatin
Coenzyme Q10
A) Active ingredient (monacolin K) same as
that of lovastatin
B) Absorption increased by vitamin C;
associated with marked CK elevations
C) Blood levels shown to be reduced by
pravastatin; data inconclusive
D) Immediate-release form generally
associated with more side effects and
hepatotoxicity than extended-release form
Answer
• C) Blood levels shown to be reduced by
pravastatin; data inconclusive
Niacin
A) Active ingredient (monacolin K) same as
that of lovastatin
B) Absorption increased by vitamin C;
associated with marked CK elevations
C) Blood levels shown to be reduced by
pravastatin; data inconclusive
D) Immediate-release form generally
associated with more side effects and
hepatotoxicity than extended-release form
Answer
• D) Immediate-release form generally
associated with more side effects and
hepatotoxicity than extended-release form
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Vitamin
D
and
coenxyme
Q10
epidemiologic markers suggest hypovitaminosis D associated with myalgia
nuclear receptors for vitamin D present in myocytes
study —looked at >600 patients in lipid clinic
120 had statin myalgia, and 82 had vitamin D levels <32 ng/mL (mean level,
28 ng/mL)
significant number of patients improved with statin plus vitamin D (50,000 IU
for 3 mo
92% myalgia-free); problems with study include subject reporting and lack of
placebo arm
Coenzyme Q10 (coQ10): blood levels shown to be reduced by pravastatin
studies —1) study saw 40% reduction in pain with coQ10 (100 mg/day),
compared to vitamin E and statin therapy
2) Japanese study compared coQ10 to placebo in patients on atorvastatin (10
mg/day)
no difference in CK levels
no reports on symptoms
3) study compared coQ10 (200 mg/day) to placebo in 44 patients on
simvastatin (40 mg/day)
No difference in pain scores
summary —data about coQ10 inconclusive
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Conclusion
muscle complaints with statin use common
mechanisms unclear
treat patients symptomatically
No outcome data suggest any other strategy reduces events
Questions and answers: ezetimibe —not likely harmful
renal disease —ezetimibe plus simvastatin (Vytorin) beneficial
no studies comparing combination drug to ezetimibe or simvastatin alone
Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) trial —ezetimibe plus
simvastatin reduced risk for MI, compared to placebo
no good outcome data for ezetimibe alone
niacin —outcome data modest (mostly surrogate data)
Small amount of mortality data available
mortality data about ezetimibe limited
over-the-counter or flush-free niacin (inositol) —not beneficial in reducing cholesterol
Slow niacin may be effective
“if it doesn’t flush, it’s not niacin”
speaker prefers extended-release formulation (Niaspan; expensive)
immediate-release niacin formulations generally associated with greater flushing and
more side effects and hepatotoxicity, compared to extended-release niacin
Which of the following should be used
initially to identify gastroesophageal
reflux disease (GERD) in a patient who
presents with heartburn and no alarm
symptoms?
A) Empiric trial of acid suppression for
4 to 8 wk
B) Esophagogastroduodenoscopy
C) Barium radiography
D) pH probing
Answer
• A) Empiric trial of acid suppression for 4 to
8 wk
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Dyspepsia and peptic
ulcer disease (PUD)
differentiated from gastroesophageal reflux disease (GERD)
intermittent epigastric pain (gnawing or aching) may improve with meals
absence of heartburn and regurgitation
reflux should not be bloody
Infantile GERD: concerns—increased or persistent forceful vomiting (rule out pyloric stenosis)
green, yellow, or bloody vomit
difficulty breathing after vomiting
food refusal that causes weight loss or poor weight gain
pain related to eating or swallowing
“test and treat”—start with H2–receptor antagonist or proton pump inhibitor (PPI)
if ineffective, can try erythromycin, antacids, or cytoprotective agents (and consult pediatric gastroenterologist)
diagnostic studies—barium swallow or upper gastrointestinal (GI) series to rule out congential abnormalities
pH probe
upper endoscop (esophagogastroduodenoscopy [EGD])
gastric emptying study
parental education—smaller or more frequent feedings
Elevate head of infant’s crib or bassinet
hold infant upright
burp child appropriately
use bottles that minimize swallowing of air
thickening formulas with cereal and introduction of solid food should be discussed with physician
involve pediatric gastroenterologist if conventional measures fail
need for surgery rare
Categorization of GERD
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nonerosive reflux disease (NERD)— 90% of cases
erosive esophagitis—Los Angeles classification system based on size and
extent of erosions across esophagus
other—Barrett esophagus
esophageal adenocarcinoma (EAC)
GERD algorithm: initiate treatment for heartburn with PPI or H2receptor antagonist
if initial response good and patient symptom- free, maintain with lowest
effective dose
screen high-risk patients (eg, white men >50 yr of age with long-term
symptoms who smoke) for Barrett esophagus
if no initial response, use step-up therapy (ie, start with lowest effective dose,
then increase to twice-daily dosing
if patient on H2-receptor antagonist, switch to PPI if patient on PPI, increase to
maximum dose or twice-daily dosing)
if still no response, confirm diagnosis with pH probing or endoscopy
if alarm symptoms present, or 8-wk trial of PPI fails, refer for endoscopy
In patients with atypical GERD
and moderate to severe persistent
asthma, twice-daily proton pump
inhibitor (PPI) therapy for 24 wk
is most likely to:
A) Reduce asthma exacerbations
B) Reduce albuterol use
C) Cause chest pain
D) Improve pulmonary function
Answer
• A) Reduce asthma exacerbations
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Diagnosis
no gold standard
50% of patients who undergo EGD have normal findings
sensitivity and specificity of pH probing high, but false-positive and false-negative
results occur
sensitivity of EGD for pathologic reflux low
Usefulness of barium radiography limited
empiric trial of acid suppression for 4 to 8 wk can identify GERD in patients without
alarm symptoms
recommend lifestyle modifications (eg, avoid eating 3-4 hr before recumbency)
Alarm symptoms: black or bloody stools
Choking
Chronic cough
Dysphagia
early satiety
Hematemesis
Hoarseness
Iron deficiency anemia
Odynophagia
unexplained weight loss
Pharmacologic treatment for atypical GERD
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H2-receptor antagonists, PPIs, and prokinetic agents
PPIs should be taken 30 to 60 min before meals
NERD—step-up therapy (H2-receptor antagonist followed by PPI if no improvement) and step-down therapy (PPI
followed by lowest dose of acid suppression) equally effective
step-down therapy does not necessarily change natural history of disease, but can decrease pharmacy costs
erosive esophagitis—PPI treatment of choice for acute and maintenance therapy
on-demand therapy—patients take medications as needed
minimizes pharmacy costs
efficacious
Newer pharmacologic agents: baclofen—gama-aminobutyric acid agonist
works on smooth muscle
frequent dosing often required (may be sedating or cause central nervous system side effects)
arbaclofen—R-isomer of baclofen
small trials showed efficacy in reducing number of heartburn events at all dose levels studied
cisapride (Propulsid)—effective in minimizing GERD symptoms, but associated with cardiac effects
mosapride—small study saw decrease in GERD symptoms and improved gastric emptying when given with
omeprazole to patients resistant to omeprazole alone
Laryngeal symptom and asthma exacerbations: no significant long-term benefits shown with twice-daily PPI for
laryngealinduced cough or chronic hoarseness
twice-daily PPI therapy for 24 wk shown to reduce asthma exacerbations in patients with moderate to severe
persistent asthma
treatment may improve quality of life, but may not reduce symptoms or albuterol use
no improvement in pulmonary function
Patients with chronic cough should be prescribed antisecretory therapy, even with no reportable GI symptoms
PPI therapy reduces symptoms of noncardiac chest pain, and can be used as diagnostic test for abnormal reflux
Classic GERD
• consider twice-daily PPI, or confirm
diagnosis with 24-hr pH monitoring
• if patient improves, taper treatment
• if symptoms recur, observe and use
maintenance therapy
• if pH test positive while patient taking PPI,
increase dose
• (if negative, reconsider diagnosis)
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Surgical treatment
fundoplication; nearly 50% of patients require PPI therapy within 1 yr after surgery
Stretta procedure
endoscopic treatment destroys top layer of mucosa to decrease acid exposure
trial showed BARRX procedure may minimize dysplastic transformation to EAC
Complementary and alternative medicine: licorice, marshmallow root, and slippery
elm (demulcents); ginger; apple cider vinegar
probiotics (controversial
may be better for lower GI issues)
digestive enzymes
relaxation, meditation, biofeedback, and acupuncture
Follow-up and surveillance: if symptoms remain unchanged in patient with previous
normal endoscopy, repeating endoscopy not recommended for 10 yr
refer patients with warning signs and symptoms that suggest complications
further diagnostic testing should be considered in patients who do not respond to acid
suppression, and in patients with history of chronic GERD at risk for complications
chronic reflux plays role in development of Barrett esophagus (unclear whether
outcomes can be changed)
antisecretory therapy reduces need for recurrent dilatation due to formation of
esophageal strictures
Which of the following are the 2 most
common prognosticators for progression
of Barrett esophagus to esophageal
adenocarcinoma (EAC)?
A) Smoking and age of patient
B) Degree of disease and age of patient
C) Presence of heartburn and male sex
D) Age of patient and male sex
Answer
• B) Degree of disease and age of patient
Barrett esophagus
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change in distal esophageal epithelium of any length that can be recognized as columnar-type mucosa on endoscopy, and
intestinal metaplasia on biopsy of tubular esophagus
screening controversial
degree of Barrett esophagus and age of patient most common prognosticators for progression to EAC
can present without heartburn
any grade of dysplasia should be confirmed by expert pathologist
Pharmacologic acid suppression controversial
Esophageal adenocarcinoma: screening should not be performed in men <50 yr of age, or in women, due to low incidence of
cancer (regardless of frequency of symptoms)
incidence in white men >60 yr of age with weekly GERD symptoms substantial and warrants screening
PPI issues: end points in PPI treatment unclear
many patients begin self-directed trial of over-the-counter PPIs
patients often left on PPI therapy without adequate follow-up
cost of inappropriate PPI use significant
risks—hip fractures related to osteoporosis
vitamin B12, calcium, zinc, vitamin C, and magnesium deficiencies
interactions with clopidogrel (particularly with omeprazole)
spontaneous bacterial peritonitis
contraindicated in pregnancy
Clostridium difficile diarrhea— associated with use of PPIs with antibiotics
43-fold increase in risk with PPIs, antibiotics, and chemotherapy
Protocols suggest stopping PPI therapy on hospital admission, unless PPI specifically indicated or if symptoms extreme
6-fold risk for community-acquired pneumonia associated with current PPI therapy started within 2 days of diagnosis
some conflicting data about risks
antiplatelet interactions
Regardless of the frequency of
symptoms, screening for EAC in
men <50 yr of age is not
recommended.
A) True
B) False
Answer
• A) True
Risks of PPI therapy include:
A) Calcium deficiency
B) Interactions with antiplatelet
agents
C) Clostridium difficile diarrhea
D) All the above
Answer
• D) All the above
Most patients with peptic ulcer
disease (PUD) do not complain
about:
A) Gnawing or burning pain
B) Pain several hours after a
meal
C) Heartburn
D) Waking between 12 am and 3
am due to pain
Answer
• C) Heartburn
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Functional dyspepsia
EGD normal
patients do not have heartburn or regurgitation, but have stomach pain
difficult to treat may overlap with other diagnoses
no proven effective pharmacotherapy
may be caused by, eg, acid secretion, delayed or accelerated emptying of stomach, hypersensitivity to stomach acid or expansion, abnormal
processing of internal organ activity by brain and nerves, infections, or altered neurohormonal responses to meals
many patients respond symptomatically to PPIs (no significant proven superiority over placebo)
Peptic ulcer disease: common symptoms—most patients do not complain about heartburn and regurgitation
gnawing, burning, or “hunger-like” pain
nonradiating, epigastric pain several hours after meal when stomach empty and transit time normal
pain often relieved by food or antacids
pain commonly awakens patient between 12 AM and 3 AM
etiologies—nonsteroidal anti-inflammatory drugs (NSAIDs)
Cyclooxygenase (COX)-2 inhibitors
Aspirin
antiplatelet agents
corticosteroids
Helicobacter pylori
upper GI cancer
Advanced age
previous upper GI bleeding
Zollinger-Ellison syndrome (hypergastrinemia; rare)
Management of dyspepsia or PUD: heartburn and/or regurgitation—manage as GERD with PPI or H2-receptor antagonist
newer data suggest greater improvement of symptoms with lower doses than with higher doses
if no response to therapy, confirm diagnosis with, eg, pH probing
EGD does not diagnose GERD or dyspepsia, but can diagnose complications
if alarm symptoms present, then treat for 8 wk and consider EGD
NSAID and COX-2 inhibitor use—consider discontinuing medication, switching to other agent, or adding PPI
symptoms usually resolve 10 to 14 days after stopping agent
GI complications shown to be minimally reduced with COX-2 inhibitors relative to standard NSAIDs and aspirin over short term (ie, few
weeks)
risk for ulcer increased in patients on long-term COX-2 inhibitors
Avoid NSAIDs in high-risk patients (particularly patients >65 yr of age), patients with history of PUD, and patients taking long-term
corticosteroids and/or anticoagulants
Nonsteroidal anti-inflammatory
drugs (NSAIDs) should be
avoided in which of the following
groups of patients?
A) Patients >65 yr of age
B) Patients with history of PUD
C) Patients taking long-term
corticosteroids and/or
anticoagulants
D) All the above
Answer
• D) All the above
Risk for upper GI bleeding and antiplatelet agents
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Clopidogrel alone, aspirin alone, NSAIDs alone, and combinations associated with increased risk
patients with history of upper GI bleeding at highest risk
PPIs appropriate in patients with multiple risk factors who require antiplatelet therapy
routine use of PPI or H2-receptor antagonist not recommended for patients at lower risk who have less potential to
benefit from prophylactic therapy
patients with recurrent GI symptoms shown to benefit from PPI while on NSAID
observational studies and one randomized trial showed inconsistent effects of cardiovascular outcomes when
clopidogrel and PPI used together
Study saw use of clopidogrel and PPI (omeprazole) reduced antiplatelet effects of clopidogrel (requires individualized
therapy)
Dyspepsia without obvious GERD or NSAID use: if patient >65 yr of age or has alarm symptoms, refer for EGD
if patient <55 yr of age with no alarm symptoms, consider testing for H pylori and treat if positive (if treatment fails,
give trial of PPI for 4 wk
if PPI fails, reassess diagnosis)
if test negative, give trial of PPI for 4 to 6 wk (if PPI fails, reassess diagnosis)
alarm symptoms—GI bleeding
heme-positive stools
melena
Hematemesis
Anemia
Penetration
Perforation
plain film radiography
best study
barium studies or EGD contraindicated
obstruction; signs of cancer (eg, weight loss, anorexia)
Choose the correct statement about Helicobacter
pyloriinfection and NSAID use.
A) H pylori eradication eliminates risk for ulcer
development in patients taking NSAIDs
B) H pylori eradication in patients taking NSAIDs is
more effective than PPI therapy in reducing
recurrence of PUD
C) Recurrence of ulcer bleeding is significantly
lower 6 mo after H pylori eradication, compared to
that in patients taking low-dose aspirin
D) H pylori eradication alone is not sufficient for
minimizing risk for upper gastrointestinal bleeding
due to PUD in patients taking NSAIDs
Answer
• D) H pylori eradication alone is not
sufficient for minimizing risk for upper
gastrointestinal bleeding due to PUD in
patients taking NSAIDs
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H pylori Infection
H pylori and NSAIDs: H pylori eradication does not eliminate risk for ulcer development in patients taking NSAIDs
Eradication in patients taking NSAIDs less effective than PPI therapy in reducing recurrence of PUD or rebleeding
recurrence of ulcer bleeding in patients taking low-dose (81 mg/day) aspirin similar to 6 mo after H pylori eradication
H pylori reduction alone not sufficient for minimizing risk for upper GI bleeding due to PUD in patients taking NSAIDs
Diagnosis and treatment of H pylori: established indications—
active PUD
confirmed history of PUD in patients not previously treated for H pylori
gastric mucosa-associated lymphoid tissue
lymphoma (especially low-grade)
endoscopic resection of early gastric cancer
uninvestigated dyspepsia
Controversial indications—nonulcer dyspepsia
GERD
NSAID use
Unexplained iron deficiency anemia
populations at higher risk for gastric cancer; antibody testing—inexpensive
widely available
good negative predictive value
positive predictive value dependent on background H pylori prevalence
not recommended after H pylori therapy
treat if positive, but do not retest with serologic study
fecal antigen testing and urease breath testing—identify active infection
excellent positive and negative predictive values regardless of prevalence
useful before and after therapy
first-line therapy—standard dose of PPI twice daily (once daily if using esomeprazole [Nexium]), clarithromycin (500 mg twice daily),
and amoxicillin (or metronidazole [500 mg twice daily])
eradication rate 70% to 85%
quadruple therapy with bismuth subsalicylate (BSS), metronidazole, tetracycline, and ranitidine (or standard dose of PPI) results in slightly higher eradication rate
(may be useful in patients allergic to penicillin; intolerance and noncompliance high)
sequential therapy—PPIs could increase
effectiveness of amoxicillin
no amoxicillin-resistant H pylori
Up to one-third of cases resistant to metronidazole
Salvage therapy—7-day regimen
eradication rate low
quadruple therapy with BSS, daily PPI, tetracycline, and metronidazole
High pill count results in side effects
triple therapy using PPI, amoxicillin, and levofloxacin to be approved
Which of the following tests
for H pylori is not recommended
after eradication therapy?
A) Fecal antigen testing
B) Serologic antibody testing
C) Urease breath testing
D) Culture
Answer
• B) Serologic antibody testing
Treatment of H pylori should not
be withheld due to concerns that
it might worsen GERD
symptoms.
A) True
B) False
Answer
• A) True
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Reassessing diagnosis
if EGD normal, consider rapid urease testing and/or histology for H pylori
culture and sensitivity testing for patients previously treated for H pylori (if detected, use salvage therapy
some patients may receive 1 round of salvage therapy)
EGD—based on histology, sensitivity and specificity excellent
often expensive
requires trained pathologist
Rapid urease breath testing—generally inexpensive
rapid results
specificity excellent and sensitivity good
sensitivity reduced in posttreatment setting
culture—specificity excellent
helps determine antibiotic sensitivity
Expensive
not widely available
Polymerase chain reaction testing—sensitivity and specificity excellent
allows for determination of antibiotic sensitivity
Difficult to standardize due to variety of methodologies
Persistent symptoms with no other established cause: usually functional dyspepsia
consider antidepressant therapy, hypnotherapy,
behavioral therapy, and prokinetic agents (ie, erythromycin or metoclopramide [eg, Octamide, Reclomide, Reglan])
controversies—clinical benefit seen in small percentage of patients after H pylori eradication
no clear evidence that H pylori consistently worsens or improves GERD symptoms
treatment of H pylori not shown to worsen GERD symptoms (do not withhold)
available data support association between H pylori and iron deficiency, but no proven cause and effect
no population-based data suggest H pylori eradication reduces incidence of gastric adenocarcinoma
Transmission of HIV by which
of the following modes makes up
75% of diagnoses?
A) Man-to-woman sexual
contact
B) Man-to-man sexual contact
C) Mother-to-child transmission
D) Injection drug use
Answer
• B) Man-to-man sexual contact
According to the Centers for Disease
Control and Prevention, which of the
following groups of patients should be
screened for HIV?
A) All patients 13 to 64 yr of age
B) All patients initiating treatment for
tuberculosis
C) All pregnant women
D) All the above
Answer
• D) All the above
Which of the following
symptoms is most common in
patients with HIV?
A) Oral lesions
B) Fever
C) Sore throat
D) Maculopapular rash
Answer
• B) Fever
Magnetic resonance imaging
(MRI) suggests HIV infection
ages brain blood flow by 15 to 20
yr.
A) True
B) False
Answer
• A) True
The Veterans Aging Cohort
Study concluded that non-HIV
biomarkers (eg, anemia, liver
disease, inflammatory markers)
were of no value in estimating
risk for death, compared to HIV
biomarkers.
A) True
B) False
Answer
• B) False
Choose the correct statement about the
pneumococcal vaccine.
A) Overall efficacy, 25%
B) Patients >65 yr of age should receive
second dose to boost immunity
C) Less effective in older patients with
longer time since immunization
D) Not cost effective when given at age
65 yr
Answer
• C) Less effective in older patients with
longer time since immunization
Compared to the standard
influenza vaccine, Fluzone HighDose influenza vaccine:
A) Should be used only in adults
≥65 yr of age
B) Is associated with lower
antibody levels
C) Contains less protein
D) Causes fewer side effects
Answer
• A) Should be used only in adults ≥65 yr of
age
Choose the correct statement about herpes
zoster vaccine.
A) Multiple studies show high efficacy in
immunocompromised hosts
B) More effective in patients ≥80 yr of age
C) Protection against postherpetic neuralgia
persists until age 80 yr
D) Data suggest immunity lasts 3 yr
Answer
• C) Protection against postherpetic neuralgia
persists until age 80 yr
Which of the following should be
considered when providing other
vaccines concomitant with herpes zoster
vaccine?
A) Concomitant vaccines should always
be avoided
B) Acceptable to give pneumococcal or
influenza vaccine
C) Vaccines should be injected in the
same arm
D) Vaccines should be injected from the
same syringe
Answer
• B) Acceptable to give pneumococcal or
influenza vaccine
Which of the following can be
used for the treatment of
pertussis?
A) Azithromycin
B) Clarithromycin
C) Trimethoprimsulfamethoxazole
D) Any of the above
Answer
• D) Any of the above
The CHA2DS2-VASc scoring
system for predicting risk for
stroke assigns 2 points to which
of the following?
A) Age 65 to 74 yr
B) Aortic plaques
C) History of stroke
D) Female sex
Answer
• C) History of stroke
Choose the correct statement about
dabigatran.
A) 150 mg twice daily shown to reduce
risk for stroke and intracerebral
hemorrhage
B) Should be taken on empty stomach
C) Preferred in patients with renal
failure or valvular heart disease
D) No known drug interactions
Answer
• A) 150 mg twice daily shown to reduce risk
for stroke and intracerebral hemorrhage
Choose the correct statement about
rivaroxaban.
A) Should be taken 2 to 3 times daily
B) Half-life longer than that of
dabigatran
C) Superior to warfarin in reducing risk
for major bleeding
D) Shown to reduce intracranial
hemorrhage by 60%
Answer
• D) Shown to reduce intracranial
hemorrhage by 60%
In patients with atrial
fibrillation (AF), risk of
developing dementia within 5 to
7 yr is increased 2- to 3-fold.
A) True
B) False
Answer
• A) True
Compared to amiodarone,
dronedarone:
A) Is associated with greater
neurotoxicity
B) Is associated with more
thyroid problems
C) Has a shorter half-life
D) Is superior in increasing
median time to recurrence of AF
Answer
• C) Has a shorter half-life
Dronedarone is contraindicated
in patients with:
A) Hypertension and
insignificant left ventricular
hypertrophy
B) Decompensated heart failure
C) Coronary disease
D) All the above
Answer
• B) Decompensated heart failure
Oxygen radical absorbance capacity is:
A) A measure of antioxidant capacity of
foods
B) The sum of vitamins C and E in
foods
C) Based on measurements of samples
from vascular tissue
D) Not affected by water content in
foods
Answer
• A) A measure of antioxidant capacity of
foods
A study looking at the antioxidant effects
of active strawberry compounds after
ingestion of a high-fat meal found:
A) Protective benefits against lowdensity lipoprotein (LDL) oxidation
B) Improvements in C-reactive protein
levels
C) Need for lower amounts of insulin to
maintain glucose
D) All the above
Answer
• D) All the above
Which of the following statements about the benefits
of chocolate is correct?
A) For reduction of blood pressure (BP), 8 g/day of
dark chocolate is as effective as 100 g/day of white
chocolate
B) Meta-analysis found decrease in BP of ≈10 mm
Hg in hypertensive patients who regularly consumed
dark chocolate
C) Meta-analysis found decrease in BP of ≈5 mm
Hg in normotensive patients who regularly
consumed dark chocolate
D) Regular consumption of dark chocolate may
decrease risk of experiencing a cardiovascular (CV)
event over 5 yr by 20%
Answer
• D) Regular consumption of dark chocolate
may decrease risk of experiencing a
cardiovascular (CV) event over 5 yr by 20%
National Health and Nutrition
Examination Survey data show a lower
incidence of stroke and CV disease
mortality (when adjusted for other CV
risk factors) with the consumption of
fruits and vegetables >3 times daily,
compared to consumption <1 time daily.
A) True
B) False
Answer
• A) True