Letters to the Editor
Screening for Dysplasia of the Hip: Weigh Harms and Benefits
TO THE EDITOR: The article, "Developmental Dysplasia of the Hip," provides an informative review and recommends screening for this disorder in infants using physical examination maneuvers based on C level evidence.1 The authors acknowledge that the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend routine screening because of the high rate of natural resolution of hip abnormalities that are found on physical examination and ultrasonography.2 However, they did not mention other considerations that led to the USPSTF's conclusion: the limited accuracy of diagnostic tests and the lack of evidence of effectiveness for, and potential harm from, surgical and nonsurgical treatments.2 These potential harms are not well studied and include unnecessary tests, health care costs, avascular necrosis, and complications of surgery and anesthesia.
The AAFP has adopted a policy that agrees with the USPSTF3; both of these recommendations apply only to infants who are asymptomatic and not to those with obvious hip dislocations or other hip abnormalities.2,3 When judging whether to perform screening tests, family physicians need to evaluate the proven and potential harms and benefits. The former are often underestimated or not considered for procedures supported only by common practice and expert opinion.
Author disclosure: Nothing to disclose.
REFERENCES
1. Storer SK, Skaggs DL. Developmental dysplasia of the hip. Am Fam Physician 2006;74:1310-6.
2. Agency for Healthcare Research and Quality. Screening for developmental dysplasia of the hip. U.S. Preventive Services Task Force: recommendation statement. Accessed April 13, 2007, at: http://www.ahrq.gov/clinic/uspstf/uspshipd.htm.
3. American Academy of Family Physicians. A-E: Recommendations for clinical preventive services. Accessed April 13, 2007, at: http://www.aafp.org/online/en/home/clinical/exam/a-e.html.
Use of Exenatide for Weight Loss in Patients with Diabetes
TO THE EDITOR: The STEPS article on exenatide injection (Byetta) concluded that it is an inconvenient drug with no proven benefits over other drugs for the management of diabetes.1 However, the authors did not discuss the weight loss benefit of exenatide in patients with diabetes who are obese.
In a clinical trial of patients with diabetes who were receiving metformin (Glucophage), the addition of exenatide was associated with progressive weight loss in obese and nonobese patients in a dose-dependent manner compared with placebo.2 When used appropriately as add-on therapy, exenatide has an advantage over sulfonylureas and insulin because it does not increase the risk of hypoglycemia.
As medical director of a bariatric practice, I have seen greater weight loss in obese patients with type 2 diabetes who were receiving exenatide compared with those taking sulfonylureas, thiazolidinediones, or insulin. I also would argue that exenatide is easier to use than insulin because of its prefilled pen design and simple dosing schedule. Medications like exenatide, which may have a positive impact on the "diabesity" epidemic, warrant additional consideration.
Author disclosure: Nothing to disclose.
REFERENCES
1. Ezzo DC, Ambizas EM. Exenatide injection (Byetta): adjunctive therapy for glycemic control. Am Fam Physician 2006;73:2213-4.
2. DeFronzo RA, Ratner RE, Han J, Kim DD, Fineman MS, Baron AD. Effects of exenatide (exendin-4) on glycemic control and weight over 30 weeks in metformin-treated patients with type 2 diabetes. Diabetes Care 2005;28:1092-100.
editor's note: This letter was sent to the authors of the STEPS article, who declined to reply.
Send letters to Kenny Lin, MD, Assistant Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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