Annals for Educators - 6 June 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives6 June 2017Annals for Educators - 6 June 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201706060 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsHepatitis B Virus Reactivation Associated With Direct-Acting Antiviral Therapy for Chronic Hepatitis C Virus: A Review of Cases Reported to the U.S. Food and Drug Administration Adverse Event Reporting SystemUse of direct-acting antivirals (DAAs) to treat patients with hepatitis C virus (HCV) infection has become the standard of care. This report from the U.S. Food and Drug Administration (FDA) focuses on an important safety concern when using DAAs in patients with HCV who are co-infected with hepatitis B.Use this paper to:Ask your learners what the potential adverse reactions to DAAs are. How does the presence of renal insufficiency, hepatic dysfunction, or cirrhosis alter plans for their use? How should patients be monitored during treatment? Use the recent In the Clinic: Hepatitis C Virus to answer these questions. Ask your learners how they would recognize and evaluate acute hepatitis occurring in a patient receiving DAA therapy for hepatitis C. How would they interpret antibody test results for hepatitis C and B?How useful are adverse event reports for assessing whether a specific drug is the cause? How are single event reports helpful, and what are their limitations? How should this report from the FDA affect practice? Use the accompanying editorial to help frame your discussion. Do your learners know when and how to report adverse drug reactions? What responsibilities do individual physicians have to report events? What about institutions? Where are reports made? Use the information at the FDA Web site to help frame your discussion. Hepatitis C Virus Infection Among Reproductive-Aged Women and Children in the United States, 2006 to 2014Hepatitis C virus (HCV) infection is a critical public health threat to young U.S. adults who use drugs. Using 2 large databases, the authors estimated the number of U.S. women of reproductive age with HCV infection from 2011 to 2014 and the subsequent number of HCV-infected babies.Use this paper to:Ask your learners whether hepatitis C may be transmitted from mother to fetus. What about hepatitis B or HIV? What other viruses of concern?Can transmission from mother to fetus be prevented?What congenitally acquired infections can your learners name? Is screening for each recommended? Do your learners screen pregnant patients for hepatitis B or C? Should they? Why might it be important?What is known about the safety of treatments for hepatitis C during pregnancy? Use the accompanying editorial to help frame your discussion. Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of PhysiciansThis guideline updates the ACP's recommendations on treatment of low bone density and osteoporosis to prevent fractures in men and women. It focuses on the comparative benefits and risks of short- and long-term pharmacologic treatments, including pharmaceuticals, calcium, vitamin D, and estrogen.Use this guideline to:Start a teaching session with a multiple-choice question. We've provided one below!What are the risk factors for osteoporosis in men and women? Ask your learners how the risk for a fragility fracture may be predicted. Do your learners know how to use and interpret FRAX (the World Health Organization's Fracture Risk Assessment Tool)?Do your learners look for osteoporosis in their patients? In men as well as women?Review how osteoporosis is diagnosed.What are the therapeutic options? What does the ACP recommend as the first-line therapy? What are the differences among the drugs and the evidence for their efficacy? Use Table 2 in the guideline. Do your learners treat men with osteoporosis?Should bone mineral density be monitored during therapy? What did the guideline developers conclude, and why? Should this guideline's recommendations apply to all patients? Use the accompanying editorial to help frame your discussion. How long should therapy be continued once initiated? Do your learners agree with the recommendations?Beyond the GuidelinesShould This Patient Have Weight Loss Surgery? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThis Grand Rounds summarizes a discussion between a bariatric surgeon and an internist on the pros and cons of weight loss surgery and lifestyle changes, both in general and in the context of a particular patient.Use this feature to:Watch a video interview of the patient with your learners.Ask them whether they would recommend bariatric surgery to this patient. Why or why not?Assign half of your team to review and concisely summarize the major arguments in favor of bariatric surgery presented by Dr. Jones, and assign the other half to summarize the arguments of Dr. Wee. After hearing both sides, what would your learners recommend?What questions would you ask a patient in helping him or her decide whether bariatric surgery might be appropriate? How would you explain the potential benefits and risks?Do your learners know what gastric banding, sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion and duodenal switch involve? Invite a bariatric surgeon to review these.What are the potential benefits of bariatric surgery beyond weight loss, and what are the potential complications? How will your learners evaluate patients in the future, and when do they think they might recommend surgery for weight loss?Irritable Bowel SyndromeIrritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders, with a prevalence of 10%–20%. It is a chronic condition characterized by abdominal pain in conjunction with altered bowel habits and abdominal distention and bloating. Are your learners prepared to recognize and manage patients with IBS?Use this review to:Ask your learners what symptoms should prompt consideration of a diagnosis of IBS.What are the diagnostic criteria? What evaluation should be performed?What are IBS-C, IBS-D, and pain-predominant IBS? Why is this differentiation important?How should patients be managed? What nonpharmacologic and pharmacologic measures should be considered?What should patients be told to expect from therapy?Download the teaching slides to help prepare an educational session. Use the provided multiple-choice questions to break up a teaching session and introduce topics for discussion. Be sure to log on and enter your answers to earn CME credit for yourself!MKSAP 17 QuestionA 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril.On physical examination, temperature is 35.8 °C (96.4 °F), blood pressure is 120/68 mm Hg, pulse rate is 62/min, and respiration rate is 14/min. BMI is 32. The remainder of his examination is unremarkable.Laboratory studies:Calcium10.9 mg/dL (2.7 mmol/L) Creatinine0.9 mg/dL (79.6 µmol/L)Parathyroid hormone 98 pg/mL (98 ng/L)25-Hydroxyvitamin D19 ng/mL (47.4 nmol/L)Estimated glomerular filtration rate>60 mL/min/1.73 m2A dual-energy x-ray absorptiometry (DEXA) scan shows T-scores of –1.3 in the right femoral neck, –1.0 in the lumbar spine, and –1.4 in the non-dominant forearm. Fracture Risk Assessment Tool (FRAX) score indicates a 13% risk of major osteoporotic fracture and a 1.9% risk of hip fracture over the next 10 years.Which of the following is the most appropriate management of this patient?A. Refer for parathyroidectomyB. Start alendronateC. Start calcitoninD. Start cinacalcetE. Start vitamin D3 (cholecalciferol)Correct AnswerE. Start vitamin D3 (cholecalciferol)Educational ObjectiveTreat primary hyperparathyroidism and concomitant vitamin D deficiency.CritiqueThe most appropriate treatment of this patient is to replete his vitamin D deficiency with a supplement such as vitamin D3 (cholecalciferol). He has primary hyperparathyroidism as shown by his elevated serum calcium and parathyroid hormone levels. However, there is a high prevalence of concurrent vitamin D deficiency and insufficiency in patients with primary hyperparathyroidism, and low levels of 25-hydroxyvitamin D can stimulate parathyroid hormone secretion in non-adenomatous glands. Because of this, measurement of vitamin D levels should be ordered as part of the evaluation of primary hyperparathyroidism, and repletion should be provided if identified. In these patients, it is important to replace their vitamin D to a level of at least 30 ng/dL (75 nmol/L). After this level is reached, the patient should be placed on a vitamin D dosage to maintain that value. The choice to use cholecalciferol versus ergocalciferol is often based on the level of vitamin D deficiency. Since ergocalciferol is more readily available in the 50,000 U form and has a shorter half-life, it is recommended when a patient's vitamin D level is less than 10 ng/mL (25 nmol/L). Cholecalciferol is often used when the level is between 20 and 30 ng/mL (50-75 nmol/L) or for maintenance. Since this patient already has hypercalcemia and low-dose repletion is desired, the lower doses (400 U daily) of vitamin D3 (over-the-counter cholecalciferol) should be used. This patient's serum calcium should be monitored at least monthly.This patient does not meet the threshold for surgery. His serum total calcium level is less than 1 standard deviation from upper limit of normal, his bone density score is not in the osteoporotic or treatment range, he is older than 50 years of age, and his glomerular filtration rate is preserved.Alendronate would be an excellent option for calcium reduction and simultaneous treatment of osteoporosis if his T-scores were lower or Fracture Risk Assessment Tool (FRAX) scores were higher. The FRAX calculator defines the 10-year fracture risk for patients with T-scores in the −1.0 to −2.5 range. The FRAX calculator incorporates multiple risk factors including sex, fracture history, femoral neck bone mineral density, steroid usage, smoking, BMI, age, and alcohol intake to determine projected fracture risk. If the risk of major osteoporotic fracture is greater than or equal to 20% or the risk of hip fracture is greater than or equal to 3%, the patient's benefit from therapy exceeds the risk and treatment should be offered.Calcitonin is an option for reducing his calcium levels, but he is currently asymptomatic and does not warrant calcium lowering.Cinacalcet, a calcimimetic agent, is another option for lowering calcium for symptomatic patients with kidney involvement. This patient has preserved kidney function and no symptoms. Due to the cost and potential side effects of cinacalcet, it would not be indicated at this time.Key PointIn patients with primary hyperparathyroidism and concomitant vitamin D deficiency, 25-hydroxyvitamin D levels should be repleted to at least 30 ng/dL (75 nmol/L) to prevent further parathyroid hormone stimulation.BibliographyHolick MF, Binkley N, Bischoff-Ferrari HA, Gordon C, Hanley D, Heaney R, Weaver C. Evaluation, treatment and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911-30.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 6 June 2017Volume 166, Issue 11Page: ED11KeywordsBariatric surgeryBone densityCalciumFood and Drug AdministrationHepatitis CHyperparathyroidismOsteoporosisVitamin DVitamin D deficiencyWeight loss ePublished: 6 June 2017 Issue Published: 6 June 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. 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