“Guidelines” galore! From Community-Acquired Pneumonia to asthma to…red meat? While you may be listening to this around Thanksgiving, we actually recorded on October 30th‒the best and spookiest time of the year. To really set the mood I wanted to include some terrible skeleton puns, but the ones I found weren’t humerus. What we do have for you are some tasty knowledge treats, courtesy of our ghosts‒oops, I mean our HOSTS‒Chris, Matt, Stuart and Paul. Join us as we review the most terrifyingly relevant research findings and creepiest clinical pearls!
Today also marks the debut of our newest Hotcakes team member, the frighteningly talented Dr. Rahul Ganatra. Rahul will now be our resident statistician/study design expert, and will use his research skulls‒no wait, SKILLS‒to provide even more insight into the practice-changing findings we love to highlight for you.
Written and Produced by: Sarah Phoebe Roberts MPH, Christopher Chiu MD
Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD, and Christopher Chiu MD
Statistics Expert: Rahul Ganatra MD
Editors: Christopher Chiu MD (audio/text), Emi Okamoto MD (text)
Cover-Art: Sarah Phoebe Roberts MPH
Music: Stuart Brigham MD
Rahul Ganatra is a Medical Attending and Director of Continuing Medical Education for the Medical Service at the VA Boston Healthcare System. He fell in love with clinical epidemiology and public health while taking night classes for his MPH during medical school. and went on to become an applied epidemiology fellow at the Centers for Disease Control and Prevention. He completed his residency and chief residency in internal medicine at Beth Israel Deaconess Medical Center, where he worked as a hospitalist for two years before coming to the VA, where he is currently the faculty mentor for the resident journal club. In addition to critical appraisal, he loves cool animal facts and subjecting friends and colleagues to tirades about animal physiology.
ACP Hospitalist Weekly. ATS/IDSA 2019 Community-Acquired Pneumonia Clinical Practice Guideline (update). Oct 09, 2019. (ACP Hospitalist Summary)
What’s the clinical question? The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have released updated guidelines for the diagnosis and treatment of Community Acquired Pneumonia (CAP).
Bottom line? Several notable changes have been made to the guidelines, which were last updated in 2007. Among them are recommendations on collecting sputum and blood cultures from inpatients, whether procalcitonin should inform treatment, adjuvant corticosteroids, beta-lactam/macrolide antibiotic therapy, and follow-up chest imaging.
What’s the deal? First major update in 30 years: (1) ICS-LABA can be prescribed for both maintenance and rescue inhaler. (2) ICS-LABA can also be started even in those with mild asthma vs previous recommendations for ICS along and “step up” to ICS-LABA. (3) Albuterol mono-therapy may be avoided entirely but GINA doesn’t specifically advise against use or as add-on therapy. (4) Budesonide-fomoterol (Symbicort in the US) or beclomethasone-formoterol (Fostair outside US).
Why the change? In Europe, patients have long been using ICS-LABA as rescue but albuterol has been a mainstay in the US. The SMART strategy (meta-analysis of 16 RCTs) in JAMA 2018 showed pts showed fewer asthma exacerbations, hospitalizations, ED visits with ICS-LABA vs SABA. The ICS-LABA had 23% fewer exacerbations than those with higher dose ICS-LABA as maintenance. In NEJM 2018, a pair of trials SYGMA 1 and SYGMA 2 (Symbicort Given as needed in Mild Asthma).
SYGMA 1 showed prn budesonide-formoterol as superior to prn terbutaline and similar to maintenance budesonide but with lower cumulative ICS dose. SYGMA 2 showed that budesonide-formoterol prn was noninferior to BID budesonide for rate of severe asthma exacerbations but inferior to symptom control (but 1/4th the amount of inhaled glucocorticoid exposure!). NEJM Editorial by Dr. Lazarus indicates that a switch could have $1 billion/year in drug savings in the US alone. [Note: revisit Curbsiders episode #102 to learn more about SYGMA 2!]
Critique? From practical standpoint, will need to work with insurances as they may not approve “early” use per previously established guidelines. Currently, no FDA indication for prn use so would technically be “off-label”.
Bottom line? GINA “strategy” is here to stay. It will take some time for providers, insurers and patients (at least in the US) to get on-board. Big change! HOTCAKES!
Zeraatkar D, Han MA, Guyatt GH, et al. Red and Processed Meat Consumption and Risk for All-Cause Mortality and Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Cohort Studies. Ann Intern Med. October 2019. doi: 10.7326/M19-0655
Today on the menu: How bad is red meat for you, really?
Study design: Systematic review of 55 large cohort studies (representing over 4 million individuals) assessing the relationship between red meat intake and mortality, cardiovascular outcomes, and T2 diabetes.
Bottom line? Low-certainty evidence suggests that reducing red meat intake is associated with a very small reduction in mortality and cardiometabolic outcomes. Many confounders to consider.
Bonus: Rahul’s back of the napkin calculations…
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