Clinical Practice Points
Hydroxychloroquine Effectiveness in Reducing Symptoms of Hand Osteoarthritis. A Randomized Trial
Osteoarthritis is a common form of arthritis, affecting up to 31% of adults older than 70 years. Effective treatment options are limited and are often associated with adverse effects. This double-blind, placebo-controlled trial examined the efficacy of hydroxychloroquine, a well-established therapy for rheumatoid arthritis, for treatment of osteoarthritis of the hand.
Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners what the clinical characteristics of hand osteoarthritis are. How should they be evaluated? What is the differential diagnosis? Use the information in In the Clinic: Osteoarthritis to help prepare for teaching.
What are the risk factors for osteoarthritis?
How do your learners treat patients with hand osteoarthritis? Do they use anti-inflammatory drugs? Which ones? Do they work?
Do the results of this randomized trial indicate that inflammation is not important in the pathophysiology of hand osteoarthritis? Why or why not? Use the accompanying editorial to help frame your discussion.
What are the potential causes of a “negative” trial? What factors need to be considered when evaluating whether negative findings indicate that a therapeutic approach should not be pursued?
Antithyroid Drugs and Congenital Malformations. A Nationwide Korean Cohort Study
Using a national database of nearly 3 million completed pregnancies, the authors analyzed the risk for congenital malformations associated with different antithyroid drugs used to treat Graves disease during the first trimester.
Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners whether they always review the drugs of pregnant patients to assess whether any are potentially teratogenic. Where do they look?
Do your learners know the FDA pregnancy categories? What do they mean? Which categories of drugs do they feel comfortable prescribing to pregnant patients? When should they consult an obstetrician?
How do your learners assess whether a drug is safe when a mother is breastfeeding?
Ask your learners how hyperthyroidism should be treated during pregnancy.
Clinical Guideline
Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update
This synopsis of the updated Kidney Disease: Improving Global Outcomes guideline, published in 2017, focuses on recommendations for diagnosis and testing for chronic kidney disease–mineral and bone disorder in adults with chronic kidney disease (CKD) and those receiving long-term dialysis. Recommendations address management of phosphate levels, calcium levels, and secondary hyperparathyroidism.
Ask your learners how CKD is classified. Use the figure in the paper's appendix to review.
What mineral and bone disorders are of particular concern among patients with CKD? Who is at risk?
Which patients with CKD should undergo dual-energy x-ray absorptiometry (DXA) testing?
How should serum phosphate and calcium levels be managed? When and how should phosphate levels be lowered?
What dietary recommendations should your learners make to their patients with CKD?
When and why should parathyroid hormone levels be measured?
How should osteoporosis be treated in patients with CKD?
Invite a nephrologist to join your discussion.
Humanism and Professionalism
On Being a Patient: Lessons From a Year With Breast Cancer: An Academic Physician's Perspective
Dr. Trautner reflects on the lessons learned since being diagnosed with breast cancer, observing that she knew them before but has put them more fully into practice since her diagnosis.
Listen to an audio recording, read by Dr. Virginia Hood.
Ask your learners whether the 3 lessons Dr. Trautner describes are “new.” If not, why do we seem to need constant reminders to practice them?
Ask a patient (or a few) whether they would be willing or even would enjoy talking with your team about the lessons they have learned since they became ill. Then, ask your patient to tell your team about these lessons during teaching rounds.
What did you learn? Can your learners draw inspiration from asking their patients about such lessons? Should we do so regularly? How might such questions be helpful to our patients?
Opportunities for Educators
Clinical Skills Proposals Wanted for Internal Medicine 2020
Interested in teaching procedural, physical examination, or communication skills?
The ACP is accepting proposals for hands-on, interactive workshops that focus on the acquisition or improvement of procedural skills, physical examination skills, and communication skills for Internal Medicine 2020, which will be held in Los Angeles, California, on April 23-25, 2020. To submit a proposal, please complete the Clinical Skills Proposal. The deadline to submit proposals is April 27, 2018.
MKSAP 17 Question 1
A 50-year-old woman is evaluated for slowly worsening joint pain in her fingers for the past 5 years. She notes swelling, morning stiffness lasting 10 minutes, and pain that is worse after housework or typing. She has no other joint pain and otherwise feels well. She reports no fevers, weight loss, rashes, alopecia, oral ulcers, dyspnea, chest pain, or abdominal pain. The patient takes no medications.
On physical examination, vital signs are normal. There is squaring, crepitus, and tenderness of the first carpometacarpal joints. Bony enlargement and tenderness over all distal interphalangeal (DIP) joints are present. Limited range of motion of the thumbs and DIP joints is noted. There is no joint warmth, redness, or effusions. The remainder of the joint examination is normal.
Which of the following is the most appropriate next step in management?
A. Anti–double-stranded DNA antibody testing
B. Antinuclear antibody testing
C. Radiography of the hands
D. Rheumatoid factor testing
Clinically diagnose osteoarthritis of the hands.
No further testing is necessary for this patient who clinically appears to have hand osteoarthritis. Osteoarthritis is a clinical diagnosis, and the cardinal symptom is pain with activity that is relieved with rest. Affected patients also typically experience morning stiffness that lasts for less than 30 minutes daily. Bony hypertrophy is commonly detected in the fingers, and Heberden and Bouchard nodes may be easily palpated. Osteoarthritis also may cause squaring or boxing of the carpometacarpal joint at the base of the thumb.
This patient has no clinical signs or symptoms suggestive of a systemic inflammatory disease and therefore does not require diagnostic testing with antinuclear antibodies (ANA) or anti–double-stranded DNA antibodies. A positive ANA test result has low predictive value when the pretest probability of systemic lupus erythematosus or a related disease is low. Therefore, this test should not be used to screen indiscriminately for the presence of rheumatologic disease. The American College of Rheumatology recommends not testing ANA subserologies such as anti–double-stranded DNA without the combination of a positive ANA and elevated clinical suspicion of autoimmune disease, which is not present in this patient.
Radiography is not needed to confirm the diagnosis of osteoarthritis in patients with a history and physical examination compatible with this condition. Clinical examination is more sensitive and specific for the diagnosis of hand osteoarthritis compared with radiography.
The key features of rheumatoid arthritis (RA) are swelling and tenderness in and around the joints. Prominent morning stiffness that usually lasts more than 1 hour characterizes early RA. Rheumatoid factor positivity is characteristic of RA, although rheumatoid factor has a low specificity for diagnosis of RA. Rheumatoid factor may be present in healthy persons, especially at older ages. Because this patient has no clinical evidence of RA, testing for rheumatoid factor is unnecessary.
Additional testing such as autoantibody measurements or radiography is unnecessary in patients with clinically diagnosed hand osteoarthritis.
Hunter DJ. In the clinic. Osteoarthritis. Ann Intern Med. 2007 Aug 7;147(3):ITC8-1-16.
MKSAP 17 Question 2
A 32-year-old woman is evaluated during a follow-up visit. She indicates that she and her husband are contemplating pregnancy, and she discontinued her oral contraceptive 2 months ago. Medical history is significant for hypertension, type 2 diabetes mellitus, and severe depression, which is currently in remission. Medications are lisinopril, metformin, atorvastatin, and sertraline. She does not smoke or use alcohol or illicit drugs. A normal Pap smear was obtained 1 year ago, no high-risk behaviors are identified, and her vaccinations are up to date.
On physical examination, blood pressure is 114/70 mm Hg. BMI is 24. The remainder of the examination is unremarkable.
A urine pregnancy test is negative.
Her lisinopril is discontinued, and she is started on a prenatal vitamin with folate.
Which of the following medications also needs to be discontinued?
D. No additional changes needed
Adjust medications in a woman who may become pregnant.
Discontinuation of atorvastatin is indicated in this patient who is planning pregnancy. Statin medications should be avoided in pregnancy due to the potential risk for congenital abnormalities. In patients actively planning pregnancy, dyslipidemia is best managed with diet and lifestyle modification for the duration of the pregnancy. Because the effects of statin use during breastfeeding are not known, their use during nursing should be discouraged.
ACE inhibitors and angiotensin receptor blockers are also contraindicated due to potential risk of teratogenicity and should be discontinued in women who are planning pregnancy, as was done in this patient. Her hypertension should be followed and treated, if needed, with another agent known to be safe in pregnancy, such as β-blockers, calcium channel blockers, or methyldopa.
Oral antidiabetic agents should be continued in women contemplating pregnancy to maintain control of diabetes mellitus. Metformin is an FDA pregnancy category B medication (no definitive studies in pregnant women but no animal studies showing risk to the fetus) and is a reasonable option for controlling this patient's hyperglycemia before pregnancy. Evidence suggests that metformin and sulfonylureas are acceptable during pregnancy; however, further management decisions are best made through co-management of medical and obstetric issues with a high-risk obstetrician.
In the treatment of depression, medication discontinuation may not be appropriate in women with a history of major or recurrent depression. Some selective serotonin reuptake inhibitors (SSRIs), including sertraline and fluoxetine, are FDA pregnancy category C (no definitive studies in pregnant women but evidence of potential harm in animal reproduction studies, although potential benefits may warrant use despite potential risks), and their use must be determined on an individual basis. Such agents may be continued if needed, but the risks and benefits of treatment, taking into account severity of depressive symptoms, stage of gestation, and associated circumstances, should be evaluated by a psychiatrist or high-risk obstetrician. SSRIs should not be stopped precipitously.
Because this patient is on a known medication classified as FDA pregnancy category X (atorvastatin), continued treatment with this agent would be inappropriate.
Statins, ACE inhibitors, and angiotensin receptor blockers are teratogenic and should be discontinued in women planning pregnancy.
Callegari LS, Ma EW, Schwarz EB. Preconception care and reproductive planning in primary care. Med Clin North Am. 2015 May;99(3):663-82.
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