Team diabetes (American College of Physicians annual session)

Prevention may require more nutritional guidance

In addition to an extensive focus on treating diabetes, several sessions at last month's American College of Physicians meeting in San Francisco explored what physicians can do to prevent the disease from ever developing -- especially in terms of weight management.

Experts recommended that these efforts go beyond the usual diet and physical activity advice and that primary care physicians be prepared to discuss commercial weight-loss programs and over-the-counter meal replacement products.

"We have to find a way to provide patients with more structure and teach people how to fill their plate," said Caroline M. Apovian, MD, director of the Nutrition and Weight Management Center at Boston Medical Center during the panel discussion, "Obesity Medicine: Emergence of a New Discipline."

Physicians also should increase familiarity with weight-loss medications. Discussing these drugs with patients could lead them to reconsider diet and exercise options, particularly in light of the modest efficacy of currently available drugs, according to the panelists.

"People who come in to see us have fundamentally failed at self-management," said Daniel H. Bessesen, MD, chief of endocrinology at the Denver Health Medical Center. "We've got to build self-efficacy in these people. The fact that they are in your office means they can't do it themselves."

Audience members responded that the additional options to facilitate weight loss were welcome but also advocated for access to mental health services to determine the underlying causes for overeating.

"It isn't all calories in, calories out," said Melinda J. Johnson, MD, assistant professor at the University of Iowa College of Medicine. "We need to address the underlying issue of why these patients eat."

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Adult ADHD care encouraged

The 30-year-old woman had an uphill battle in school and always thought herself lazy and stupid. It was not until her daughter was diagnosed with attention-deficit/hyperactivity disorder that she approached her own doctor with the possibility that she might have the condition, too.

When this suspicion was confirmed, she cried from the relief of learning that she could have had more potential than anyone, including herself, had given her credit for.

"This patient spent all those years struggling, in some ways needlessly," said Howard H. Schubiner, MD, clinical professor in the departments of internal medicine, pediatrics, and psychiatry and behavioral neurosciences at Wayne State University in Southfield, Mich.

Patients like this are why Dr. Schubiner told a packed house at a session during the American College of Physicians meeting last month that internists and other primary care physicians must become more involved in the treatment and management of adult cases of ADHD.

"This is a disorder of the whole fabric of daily life," Dr. Schubiner said. "It's easy to treat, and my patients are so thankful."

An additional impetus for primary care involvement, Dr. Schubiner added, is the fact that drugs used to treat it have cardiac contraindications that are more likely to be dealt with in this setting than in a mental health setting. For example, it's crucial to get hypertension under control before prescribing stimulants.

"For the most part, psychiatrists don't take blood pressures on their patients," he said. "There's no question that this should be treated by primary care."

Dr. Schubiner also recommended screening for ADHD among adults who have children with the condition, have substance abuse disorders themselves, appear to be underachievers or have more frequent car crashes than average. Those with depression or anxiety disorders also should be considered as possibly having ADHD, although more complicated cases, such as those that might involve bipolar disorder, should be referred.

"If it's not clear, get help. It's too important to be casual about this," he said.

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Treatment tips

Here are some treatment tips from the meeting:

From asthma therapy to sleep apnea, physicians at the American College of Physicians meeting took away useful diagnostic information.

"When a patient comes to your door, they're coming for symptom relief," said Ralph Gonzales, MD, MSPH, associate professor of medicine, epidemiology and biostatistics at the University of California, San Francisco, School of Medicine. "If we address that, we'll get a lot further, especially when it comes to antibiotic overuse."

He also recommended that doctors take care in naming the condition. For example, patients were far less likely to demand antibiotics for a chest cold than for bronchitis. Delayed prescriptions -- those filled only if the symptoms are not improved by a certain date -- also are worth considering.

Male menopause treatment is a judgment call. Treating the male equivalent of menopause with testosterone is an ethical quandary but should be considered if the patient wants to do so.

"It's your judgment to make," said Stanley G. Korenman, MD, professor of medicine and endocrinology at the David Geffen School of Medicine, University of California, Los Angeles, during a panel discussion.

The situation is tricky because male menopause is less defined and understood than the female version. Lab tests for testosterone levels are not reliable, and false-positives could result from normal daily variations.

It is also unclear whether declining testosterone in an aging male is abnormal, and little research has followed the long-term impact of testosterone supplementation in this age group. He suggested that diet and exercise or drugs addressing specific symptoms could be more appropriate choices.

Does timing matter for GERD pills? Only about 27% of patients with gastroesophageal reflux disease who are prescribed proton pump inhibitors take their pills at the correct time, and less than 10% take them at the most optimal time, according to a poster presentation.

Symptoms were not affected by the fact that the drugs were not taken on a timely basis, and the researchers from Providence and St. Joseph Mercy Hospitals, Mich., suggest that this could mean that drug timing might not be that important or that patients are being misdiagnosed.

Questions about sleep can lead to apnea diagnosis. Asking patients about snoring, falling asleep in inappropriate situations and the quality of their sleep might identify those at risk for obstructive sleep apnea and could allow physicians to initiate treatment without a full sleep study, according to a poster presented by researchers from Staten Island University Hospital, New York.

Authors of the paper suggested that routine use of a simple patient questionnaire could lead to quicker diagnosis and treatment.

Patients who understand asthma therapy visit ED less. Asthmatics who understand how to take prophylaxis medication are less likely to visit the emergency department, according to a poster presented by researchers from Eastern Virginia Medical School, Norfolk. Authors suggested that spending time ensuring that patients understand their medications might be cost-effective.

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Research findings: COX-2 inhibitors; dementia treatment; screening for abdominal aneurysm; statins

Physicians should become familiar with the basic science behind any widely prescribed new drug to avoid future situations similar to the recent controversy over COX-2 inhibitors, according to the "Hot Off the Press: New Developments that Will Affect Your Practice" panel at last month's American College of Physicians' meeting in San Francisco.

"Read up on that drug you're going to use a lot to at least have a more humble opinion of what the capabilities are and what the problems might be," said Allan H. Goroll, MD, one of the panelists and an internist at Massachusetts General Hospital in Boston.

This drug class made headlines last fall when Vioxx (rofecoxib) was pulled from the market by manufacturer Merck & Co. because of data linking it to increased risk of cardiovascular events. Since then, Bextra (valdecoxib) also has been withdrawn, and COX-2s in general have come under Food and Drug Administration scrutiny.

Audience members responded, however, that many physicians don't have time to keep up with basic science and evaluate new findings. "I don't think we can ignore basic science, but we have to be cautious, because it's hard to know in the whole scheme of things how important one study really is," said Charles R. Welford, MD, a general internist from Rockford, Ill.

Experts recommended that patients exhaust options such as combining a more traditional nonsteroidal anti-inflammatory drug with a proton pump inhibitor before trying a COX-2 inhibitor.

Meanwhile, panelists cited other findings as significant enough to make waves in the practice setting:

• Pharmacologic therapies are not particularly effective for management of dementia, according to a review paper in the Feb. 2 Journal of the American Medical Association.
• Men ages 65 to 75 who have ever been smokers should receive a one-time screening with ultrasonography for evidence of aortic abdominal aneurysm, according to recommendations by the U.S. Preventive Services Task Force.
• Patients with stable coronary disease should be treated with intensive lipid-lowering therapy, according to a paper in the April 7 New England Journal of Medicine.

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