The Year's Notable Guidelines: Highlights for Primary Care


The Year's Notable Guidelines: Highlights for Primary Care

Disclosure: Neil Skolnik, MD, has disclosed the following relevant financial relationships:

Serve(d) on the advisory board for: AstraZeneca; Teva; Eli Lilly and Company; Boehringer Ingelheim; Sanofi; Sanofi Pasteur; GlaxoSmithKline; Merck; Bayer

Serve(d) as a speaker or a member of a speakers bureau for: AstraZeneca; Boehringer Ingelheim; Eli Lilly and Company; GlaxoSmithKline

Received research grant from: Sanofi; AstraZeneca; Boehringer Ingelheim; GlaxoSmithKline; Bayer

Received income in an amount equal to or greater than $250 from: AstraZeneca; Teva; Eli Lilly and Company; Boehringer Ingelheim; Sanofi; Sanofi Pasteur; GlaxoSmithKline; Merck; Bayer

What we do as primary care clinicians is challenging: seeing people all day long and keeping up with the ever-changing evidence. It is also rewarding. We live in an amazing age where each year, we are privileged to witness incredible advances in medicine.

I'm Dr Neil Skolnik, and these are the highlights of important guidelines for primary care that came out during the past year.

Let's start with asthma. The big change in the Global Initiative for Asthma (GINA) recommendations for asthma care have to do with the recognition that even patients with mild asthma can have severe exacerbations. Thus, GINA no longer recommends that patients with mild asthma be treated with albuterol alone, but rather that an inhaled corticosteroid (ICS) should be used whenever a short-acting beta-agonist (SABA) is used. Patients with mild (step 1) asthma now have three choices. They can be treated with low-dose ICS-formoterol as needed (which is not a US Food and Drug Administration [FDA]-approved approach), or as-needed low-dose ICS-albuterol, using budesonide-albuterol in one canister (now FDA approved). They can also choose to take ICS daily, using either albuterol or ICS-SABA as needed for symptoms.

The point to remember is that patients have fewer exacerbations when using an ICS-containing reliever medication. Per GINA, budesonide-albuterol is preferred over albuterol alone as reliever or rescue therapy to reduce the risk for exacerbations across all severities of asthma.

Next, I'll touch on the high points of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. The explosion of knowledge about chronic kidney disease (CKD) over the past decade has been nothing short of phenomenal. We now have medicines that can slow the rate of decline in kidney function, help patients avoid dialysis, and decrease the elevated risk for heart disease in people with CKD.

We should screen people at high risk for CKD -- patients with diabetes, certainly -- and consider screening those with hypertension or cardiovascular disease. Screening should include a serum creatinine level and a urine albumin-to-creatinine ratio ( UACR).

To substantially slow the rate of decline in kidney function and lower the elevated risk for adverse cardiovascular outcomes, good blood pressure control with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker is recommended, titrated to the highest or near-highest approved dose. Also recommended are the sodium-glucose cotransporter 2 (SGLT2) inhibitors. The details about who should be prescribed an SGLT2 inhibitor are important:

Once started, the SGLT2 inhibitor can be continued until dialysis is initiated, even if the eGFR falls below 20 mL/min/1.73 m.

For patients with diabetes, a nonsteroidal mineralocorticoid receptor antagonist, finerenone, is suggested for adults with type 2 diabetes, an eGFR > 25 mL/min/1.73 m, normal serum potassium concentration, and persistent albuminuria (> 30 mg/g) despite other standard-of-care therapies. Note that the FLOW trial of semaglutide in patients with diabetes and CKD was published after the guidelines were released, so it is not clear where semaglutide would fit in. The FLOW trial showed benefit on slowing progression of kidney disease and decreasing major cardiovascular events and the risk for death from any cause, all of which are important results.

Next up, prostate cancer screening. It's important to recognize that many organizations -- the American Academy of Family Physicians (AAFP), the American College of Physicians, and others -- have recommendations that do not all align. What they all agree on is the importance of shared decision-making because the risks and benefits of prostate-specific antigen (PSA) screening are not entirely clear. On one end of the spectrum are the AAFP recommendations, which do not recommend routinely discussing PSA-based screening if the patient does not request it.

Here are particularly helpful recommendations in the American Urological Association guidelines:

One of the most popular guidelines of the year was the Endocrine Society's guideline on vitamin D testing and treatment. All adults should get the Institute of Medicine's recommended amount of vitamin D (600 IU daily for those 50-70 years of age and 800 IU daily for those older than 80 years). For adults aged 18-74 years who do not have prediabetes, the guidelines suggest against routinely testing for vitamin D deficiency and against routine supplementation. For adults with prediabetes, vitamin D supplementation is recommended to reduce the risk for progression from prediabetes to diabetes by approximately 10%-15%.

For adults over age 75, it is a different story. Because about 20% of older adults have low vitamin D levels, and supplementation is safe, the guidelines suggest against testing vitamin D levels and recommend empirical vitamin D supplementation. The guidelines do not specify a specific dose of vitamin D, but based on the doses used in trials of adults aged 75 or older, I'm going to suggest that a dose of 1000-2000 IU daily is a reasonable choice for older adults. In the prediabetes trials, a higher average dose was used, so a dose of 3000-4000 IU might make sense for this group.

The recommendation for first-line treatment of migraine headaches saw a big change this year. To put it simply, the American Headache Society now recommends calcitonin gene-related peptide (CGRP) agents as a first-line option for preventive therapy in people with migraine headaches. Many clinical studies have shown CGRP-targeting therapies to be as or even more effective than traditional first-line agents such as tricyclics, beta-blockers, and topiramate at decreasing the number of migraine days per month and the decreasing the severity of migraine headaches.

CGRPs are well tolerated and safe. They are also effective in individuals who have failed multiple other first-line therapies, so they can be used as first-line therapy in patients with difficult-to-treat migraine. Monoclonal antibody CGRPs are easy to use as a monthly subcutaneous injection. For a quick reference, see the table I put together on generic and brand names, as well as dosing and monthly cost. Pick one CGRP and get to know it. It's a useful therapy that patients appreciate.

Next are the revised criteria for diagnosis and staging of Alzheimer's disease (AD) from the Alzheimer's Association Workgroup. Talk about a big change in the way we think about a disease. Until recently, AD was the diagnosis that remained after we ruled out other causes of dementia with blood tests and imaging. Moving forward, AD will be ruled in using blood-based biomarkers. The key principle that this guideline lays out is that AD is defined by its biology -- neuropathologic changes in the brain characterized by deposition of amyloid and tau protein. A recent paper in JAMA showed that blood-based biomarkers, using the ratio of two tau proteins and two amyloid proteins, were accurate in identifying AD more than 90% of the time.

Once there is regulatory approval of the blood biomarkers, which is coming soon, our whole approach to the diagnosis of the cause of dementia will change. What will that look like? In addition to ordering an MRI to look for structural lesions and evidence of multi-infarct dementia, we will also be ordering blood tests to see if a person with mild cognitive impairment or dementia has AD.

Next I want to talk about apolipoprotein B (apoB) and the Expert Clinical Consensus from the National Lipid Association that gives us guidance. ApoB is the main protein that is found on all atherogenic lipoproteins and predicts cardiovascular risk more accurately than LDL cholesterol ( LDL-C). Although it is often correlated with LDL-C, it can be discordant, and this is when it is most useful. This brings us to the two circumstances where apoB testing is helpful:

Remember, this guideline does not suggest that the standard of care should be measurement of apoB in all patients, but rather that apoB can provide helpful information for decision making for specific patients and is most likely to be helpful in those with hypertriglyceridemia, diabetes, visceral adiposity, insulin resistance/ metabolic syndrome, or low HDL-C.

A guideline on urinary tract infections (UTIs) from the WikiGuidelines group was published in JAMA Open Network. First, always put the results of a urinalysis into clinical perspective because it is an imperfect test. The sensitivity of leukocyte esterase is only about 80%, with even lower specificity. The sensitivity of nitrite on urinalysis is below 50%, meaning the test is negative more than half the time when someone actually has a UTI, so don't withhold treatment solely because the nitrite test is negative. The specificity of urine nitrite is greater than 90%, so if it is positive, the person has bacteria in the urine.

For healthy people with simple bladder infections, urine cultures are not necessary -- just treat empirically. For uncomplicated cystitis, first-line treatment is nitrofurantoin for 5 days. Other first-line agents include trimethoprim- sulfamethoxazole (TMP-SMX) for 3 days; fosfomycin (oral) single dose; or a beta-lactam (most commonly a first-generation cephalosporin).

It is important to distinguish uncomplicated UTI from pyelonephritis, which requires a decision about inpatient vs outpatient treatment depending upon how sick the patient is. For pyelonephritis, always get a urine culture. For outpatient treatment of pyelonephritis, the guideline suggests that both TMP-SMX and first-generation cephalosporins are reasonable first-line agents, with fluoroquinolones being a reasonable choice as well. Ceftriaxone is a good choice for inpatient treatment.

For women with recurrent UTIs, consider doing something to decrease the rate of recurrence. That can be increasing water intake if the patient doesn't drink a lot, or encouraging cranberry juice intake. Methenamine hippurate is FDA-approved for prevention of UTIs. It works by releasing formaldehyde in the urine, which is bacteriostatic. You can also use antibiotic prophylaxis -- postcoital or daily administration of TMP-SMX or nitrofurantoin, which can decrease UTI recurrence by approximately 85%. For postmenopausal women, don't forget topical vaginal estrogen, which can lead to a 50%-90% reduction in the incidence of recurrent UTIs.

There have been many important changes and updates over the past year that further allow us to do amazing things for our patients. Medicine is truly one of mankind's greatest achievements, harnessing science to fight disease, improve health, and promote well-being.

In patients already treated with statins, in whom we are deciding whether treatment intensification is warranted. If the LDL-C is at goal and apoB is above threshold, treatment intensification may be considered.

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