Annals for Educators - 15 August 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives15 August 2017Annals for Educators - 15 August 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201708150 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsContinued Statin Prescriptions After Adverse Reactions and Patient Outcomes. A Cohort StudyGuidelines recommend statins for prevention of cardiovascular disease, but many patients discontinue statin therapy because of adverse events. Studies show an association between discontinuation of statin treatment and increased risk for cardiovascular events and death. This study compared the rates of cardiovascular events and mortality among patients who continued to receive statin prescriptions with those in patients who stopped therapy after an adverse event.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to list possible adverse events associated with statin therapy. How frequently do they occur? What evaluation or action is indicated for each?Watch this month's episode of the Annals Consult Guys, “Is It Statin Myalgia? What a Pain!” How do your learners assess whether patients who are prescribed statins are taking them? How often do they think drugs such as these are not being taken regularly (or at all) even if patients say they are taking them? Do the results of this study alter the importance your learners will assign to assessing adherence to statin prescriptions?How should your learners counsel patients who report muscle aches or other intolerance to statins? The editorialist believes that many patients' reports of statin-related adverse events represent a “nocebo” effect. What does that mean? Do your learners agree? The editorialist stresses that physicians must counter the “dangerous cults” of nonscientific and misleading information (frequently found on the Internet) by educating patients. Pretend to be a patient who has read about the dangers of statins on the Internet. How should your learners respond?Some patients who report intolerance to statin medications may be assessed and successfully restarted on medication by using an “n-of-1” trial. Review a study of such an approach specifically related to statin use. Cardiovascular Disease Among Transgender Adults Receiving Hormone Therapy. A Narrative ReviewPrescription of cross-sex hormone therapy is increasingly desired by transgender persons whose sex assigned at birth differs from their gender identity. Physicians, other health care professionals, and patients need to understand the risks and benefits of this important component of gender-affirming care.Use this paper to:Ask your learners what hormonal treatments are used in gender-affirming care. What are the goals of such treatments? How are they used, and how is treatment response monitored?What are the long-term health concerns for the use of testosterone and estrogen in transgender men and women, respectively? What are the limits to what is known? Why might information from studies of cisgender men and women be inadequate?Are clinicians with the necessary experience available to patients at your institution to provide cross-sex hormone therapy for transgender adults? The authors of this article note that 50% of transgender adults report having to teach their clinicians how to care for them. Does this surprise your learners? How would they react if a patient aimed to “educate” them about a clinical issue with which they have insufficient expertise?Medicine and Public IssuesThe Pharmaceuticalization of the Tobacco IndustryThe use and acceptance of e-cigarettes and other noncombustible tobacco products have been growing. The authors point to a concerted effort by tobacco companies to rehabilitate their image as providers of health-related products and argue that such “pharmaceuticalization” of this industry has important consequences for public health.Use this paper to:Ask your learners why tobacco companies might benefit from the growing use and acceptance of e-cigarettes.Do your learners think that rehabilitation of the tobacco industry's image as providers of health-related products poses a threat to public health?Could e-cigarettes be useful as harm reduction tools for some patients who smoke combustible cigarettes? What are the risks? Might some patients who may otherwise never have used tobacco products try and become addicted to e-cigarettes? Is this harmful? Where might it lead?How do we balance the potential benefits and harms of e-cigarettes? Can we balance them?Do your learners ask their patients whether they use e-cigarettes? What counsel do they provide if the answer is yes?Understanding What You ReadAnnals Understanding Clinical Research: Evaluating the Meaning of a Summary Estimate in a Meta-analysisIn meta-analyses, researchers combine data from individual studies into a summary measure to describe the benefits or harms of an intervention. This installment of the “Understanding Clinical Research” series addresses issues that readers should consider when evaluating the meaning of a summary estimate and understanding to whom and under what circumstances it applies.Use this paper to:Ask your learners what the goals of a meta-analysis are. Why is it important to assess the studies that are included in a meta-analysis when assessing the value of the analyses' conclusions? What aspects of the included studies should be evaluated?Might it be inappropriate to “pool” the results of studies performed in markedly different populations, with different interventions or definitions of the relevant end points? Are your learners aware that some meta-analyses are performed despite these problems? Help your learners understand why it is problematic to assume these analyses are meaningful.What does the I2 value mean?How does one read a forest plot? Invite an expert in systematic review and meta-analysis to join your discussion.Opportunities for EducatorsTeaching Ultrasonography Skills at the ACP Internal Medicine Meeting 2018ACP seeks faculty to provide hands-on teaching for a Point-of-Care Ultrasound Pre-Course for Internists and Hospitalists that will be held during Internal Medicine Meeting 2018 on April 17 and 18 in New Orleans, Louisiana. Faculty members will receive a stipend and complimentary registration to the meeting. Learn more. MKSAP 16 QuestionA 56-year-old man presents for evaluation of elevated liver chemistry test results that were obtained during an application for life insurance. At an office visit 12 weeks ago, he was started on simvastatin for dyslipidemia. He has not experienced any side effects with this medication and specifically does not have nausea, vomiting, or abdominal pain.On physical examination today, blood pressure is 140/80 mm Hg; vital signs are otherwise normal. BMI is 29. There is no scleral icterus, hepatomegaly, or abdominal tenderness.Laboratory values:12 Weeks AgoCurrentAlanine aminotransferase28 units/L76 units/LAspartate aminotransferase21 units/L63 units/LTotal bilirubin0.8 mg/dL (13.6 µmol/L)1 mg/dL (17.1 µmol/L)Peer ComparisonThis data is from pre-publication test-takers who did not have access to the content of MKSAP 16.Which of the following is the most appropriate management?A. Discontinue simvastatinB. Measure serum antibodies to hepatitis B and CC. Order liver ultrasonographyD. No change in managementCorrect AnswerD. No change in managementEducational ObjectiveManage elevated liver chemistry test results in a patient on statin therapy.CritiqueNo change in management of this patient's lipid levels is indicated, including repeat liver chemistry testing or change in statin medication. Statins work by inhibiting the hepatic HMG-CoA reductase enzyme, and can be associated with an elevation of aminotransferase levels, and rarely hepatotoxicity and acute liver failure. Aminotransferase elevations less than three times the upper limit of normal may occur in up to 3% of statin-treated patients. Conversely, statin-related hepatotoxicity (defined as alanine aminotransferase level more than three times the upper limit of normal and total bilirubin level more than twice the upper limit of normal) and acute liver failure are very rare. Acknowledging this, the FDA has recently recommended that baseline liver chemistry tests be measured prior to initiating statin therapy and then only as clinically indicated thereafter.This patient has minor elevations of aminotransferase levels that were discovered incidentally. Statin-related minor elevation of aminotransferase levels is usually asymptomatic, occurs within the first 12 weeks of therapy, and resolves spontaneously without discontinuation of therapy. It is thought to represent a “leak” of liver enzymes related to increased hepatocyte permeability; there are no associated histopathologic changes. This phenomenon has been observed with all of the statins but is more common with higher doses.Simvastatin should only be discontinued if there is clinical evidence of drug-related hepatotoxicity. This occurs most commonly in the setting of underlying liver conditions or as a result of drug interactions (such as acetaminophen).In the setting of possible hepatotoxicity on treatment, persistent elevations of liver chemistry test results after discontinuation of the statin warrant further evaluation. Common causes of liver disease should be sought, including hepatitis C virus infection, nonalcoholic fatty liver disease, and autoimmune hepatitis. Serum antibody studies and liver ultrasonography may be helpful in this situation, and statin therapy should be withheld until investigations are complete.Key PointBaseline liver chemistry tests should be obtained in patients prior to starting statin therapy; however, routine follow-up of liver chemistry testing is not needed and is indicated only if there is clinical evidence of liver dysfunction.Bibliography FDA Drug Safety Communication: Important safety label changes to cholesterol-lowering statin drugs. Additional Information for Healthcare Professionals. Accessed June 7, 2012. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 15 August 2017Volume 167, Issue 4Page: ED4KeywordsAcute liver failureAdverse eventsAminotransferasesDrugsInternetLiverLiver diseasesPrevention, policy, and public healthStatinsUltrasound imaging ePublished: 15 August 2017 Issue Published: 15 August 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...