ITEMS IN AFP WITH MESH TERM:
Drug Therapy, Combination
Diabetic Nephropathy: Common Questions - Article
ABSTRACT: Diabetic nephropathy, or diabetic kidney disease, affects 20 to 30 percent of patients with diabetes. It is a common cause of kidney failure. Diabetic nephropathy presents in its earliest stage with low levels of albumin (microalbuminuria) in the urine. The most practical method of screening for microalbuminuria is to assess the albumin-to-creatinine ratio with a spot urine test. Results of two of three tests for microalbuminuria should be more than 30 mg per day or 20 mcg per minute in a three- to six-month period to diagnose a patient with diabetic nephropathy. Slowing the progression of diabetic nephropathy can be achieved by optimizing blood pressure (130/80 mm Hg or less) and glycemic control, and by prescribing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. Patients with diabetes and isolated microalbuminuria or hypertension benefit from angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. In the event that these medications cannot be prescribed, a nondihydropyridine calcium channel blocker may be considered. Serum creatinine and potassium levels should be monitored carefully for patients receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. These medications should be stopped if hyperkalemia is pronounced.
ABSTRACT: Hepatitis C virus is the most common chronic blood-borne infection in the United States. The advent of new treatment regimens using pegylated interferons in combination with ribavirin has led to improved sustained viral response rates for some genotypes in large multicenter trials. Advances in the management of side effects and toxicities have expanded the pool of treatable patients. A recent National Institutes of Health consensus conference recommended that all patients who have bridging hepatic fibrosis and moderate inflammation together with detectable viremia should receive treatment with pegylated interferon and ribavirin. Unfortunately, these medications are very expensive and have significant side effects. Hematologic toxicities include anemia and leukopenia. These can be managed with close monitoring, use of growth factors, or dose reductions. Depression also can be caused or exacerbated by these medicines and may require treatment with a selective serotonin reuptake inhibitor, comanagement with psychiatry, or cessation of pegylated interferon and ribavirin treatment. Contraception is imperative because ribavirin is highly teratogenic. Influenza-like symptoms of fatigue, nausea, and mild fevers can be helped by quality patient education and support including frequent office visits. Data from randomized controlled trials demonstrating improvements in long-term survival as a result of treatment are not yet available, but it appears that patients who have no detectable virus six months after treatment have a good chance of remaining virus free for at least five years.
ABSTRACT: Chronic shoulder pain is a common problem in the primary care physician's office. Effective treatment depends on an accurate diagnosis of the more common etiologies: rotator cuff disorders, adhesive capsulitis, acromioclavicular osteoarthritis, glenohumeral osteoarthritis, and instability. Activity modification and analgesic medications comprise the initial treatment in most cases. If this does not lead to improvement, or if the initial presentation is of sufficient severity, a trial of physical therapy that focuses on the specific diagnosis is indicated. Combined steroid and local anesthetic injections can be used alone or as an adjuvant to the physical therapy. The site of the injection (subacromial, acromioclavicular joint, or intra-articular) depends on the diagnosis. Injections into the glenohumeral joint should be done under fluoroscopic guidance. Symptoms that persist or worsen after six to 12 weeks of directed treatment should be referred to an orthopedic specialist.
ABSTRACT: Vibrio vulnificus infection is the leading cause of death related to seafood consumption in the United States. This virulent, gram-negative bacterium causes two distinct syndromes. The first is an overwhelming primary septicemia caused by consuming raw or undercooked seafood, particularly raw oysters. The second is a necrotizing wound infection acquired when an open wound is exposed to warm seawater with high concentrations of V. vulnificus. Most patients, including those with primary infection, develop sepsis and severe cellulitis with rapid development to ecchymoses and bullae. In severe cases, necrotizing fasciitis can develop. Case-fatality rates are greater than 50 percent for primary septicemia and about 15 percent for wound infections. Treatment of V vulnificus infection includes antibiotics, aggressive wound therapy, and supportive care. Most patients who acquire the infection have at least one predisposing immunocompromising condition. Physician awareness of risk factors for V. vulnificus infection combined with prompt diagnosis and treatment can significantly improve patient outcomes. (Am Fam Physic
ABSTRACT: Combination therapy of hypertension with separate agents or a fixed-dose combination pill offers the potential to lower blood pressure more quickly, obtain target blood pressure, and decrease adverse effects. Antihypertensive agents from different classes may offset adverse reactions from each other, such as a diuretic decreasing edema occurring secondary to treatment with a calcium channel blocker. Most patients with hypertension require more than a single antihypertensive agent, particularly if they have comorbid conditions. Although the Joint National Committee guidelines recommend diuretic therapy as the initial pharmacologic agent for most patients with hypertension, the presence of "compelling indications" may prompt treatment with antihypertensive agents that demonstrate a particular benefit in primary or secondary prevention. Specific recommendations include treatment with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, beta blockers, or aldosterone antagonists for hypertensive patients with heart failure. For hypertensive patients with diabetes, recommended treatment includes diuretics, beta blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and/or calcium channel blockers. Recommended treatment for hypertensive patients with increased risk of coronary disease includes a diuretic, beta blockers, angiotensin-converting enzyme inhibitors, and/or calcium channel blocker. The Joint National Committee guidelines recommend beta blockers, angiotensin-converting enzyme inhibitors, and aldosterone antagonists for hypertensive patients who are postmyocardial infarction; angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for hypertensive patients with chronic kidney disease; and diuretic and angiotensin-converting enzyme inhibitors for recurrent stroke prevention in patients with hypertension.
ABSTRACT: The primary goal of antiretroviral therapy for human immunodeficiency virus (HIV) infection is suppression of viral replication. Evidence indicates that the optimal way to achieve this goal is by initiating combination therapy with two or more antiretroviral agents. The agents now licensed in the United States for use in combination therapy include five nucleoside analog reverse transcriptase inhibitors (zidovudine, didanosine, zalcitabine, stavudine and lamivudine), two nonnucleoside reverse transcriptase inhibitors (delavirdine and nevirapine) and four protease inhibitors (saquinavir, ritonavir, indinavir and nelfinavir). Current recommendations suggest that antiretroviral therapy be considered in any patient with a viral load higher than 5,000 to 20,000 copies per mL, regardless of the CD4+ count. Selection of the combination regimen must take into account the patient's prior history of antiretroviral use, the side effects of these agents and drug-drug interactions that occur among these agents and with other drugs as well. Because of the potential for viral resistance, nonnucleoside reverse transcriptase inhibitors and protease inhibitors should only be used in combination therapy. Antiretroviral agents are rapidly being developed and approved, so physicians must make increasingly complex treatment decisions about medications with which they may be unfamiliar.
Management of Dyslipidemia in Adults - Article
ABSTRACT: The importance of treating dyslipidemias based on cardiovascular risk factors is highlighted by the National Cholesterol Education Program guidelines. The first step in evaluation is to exclude secondary causes of hyperlipidemia. Assessment of the patient's risk for coronary heart disease helps determine which treatment should be initiated and how often lipid analysis should be performed. For primary prevention of coronary heart disease, the treatment goal is to achieve a low-density lipoprotein (LDL) cholesterol level of less than 160 mg per dL (4.15 mmol per L) in patients with only one risk factor. The target LDL level in patients with two or more risk factors is 130 mg per dL (3.35 mmol per L) or less. For patients with documented coronary heart disease, the LDL cholesterol level should be reduced to less than 100 mg per dL (2.60 mmol per L). A step II diet, in which the total fat content is less than 30 percent of total calories and saturated fat is 8 to 10 percent of total calories, may help reduce LDL cholesterol levels to the target range in some patients. A high-fiber diet is also therapeutic. The most commonly used options for pharmacologic treatment of dyslipidemia include bile acid-binding resins, HMG-CoA reductase inhibitors, nicotinic acid and fibric acid derivatives. Other possibilities in selected cases are estrogen replacement therapy, plasmapheresis and even surgery in severe, refractory cases.
ABSTRACT: Patients receiving antidepressant monotherapy may be partially or totally resistant to treatment in 10 to 30 percent of cases. In patients who have experienced only partial treatment results, the clinician should first consider optimizing antidepressant dosage or lengthening therapy. Antidepressant drug substitution should generally be reserved for use in patients who haven't responded at all (nonresponders). Combining two or more antidepressants is generally not recommended, as this approach may obscure adequate monotherapy evaluation and lead to significant adverse effects or drug-drug interactions. Use of electroconvulsive therapy is recommended in patients with psychotic and severe refractory depression. Augmentation therapy is often efficacious in patients who exhibit a partial antidepressant response. Lithium and thyroid hormone have been the most extensively studied augmentative agents but, more recently, pindolol and buspirone have also been used for this purpose.
Managing Pain in the Dying Patient - Article
ABSTRACT: End-of-life care can be a challenge requiring the full range of a family physician's skills. Significant pain is common but is often undertreated despite available medications and technology. Starting with an appropriate assessment and following recommended guidelines on the use of analgesics, family physicians can achieve successful pain relief in nearly 90 percent of dying patients. Physicians must overcome their own fears about using narcotics and allay similar fears in patients, families and communities. Drugs such as corticosteroids, antidepressants and anticonvulsants can also help to alleviate pain. Anticonvulsants can be especially useful in relieving neuropathic pain. Side effects of pain medications should be anticipated and treated promptly, but good pain control should be maintained. The physical, psychologic, social and spiritual needs of dying patients are best managed with a team approach. Home visits can provide comfort and facilitate the doctor-patient relationship at the end of life.
ABSTRACT: Except for a small subset of patients with angina whose survival is improved with coronary artery bypass surgery, chronic stable angina can be appropriately managed with medical therapy in the vast majority of patients. Drug therapy includes aspirin, beta-adrenergic blockers, cholesterol-lowering agents and other anti-ischemic drugs that can ameliorate angina and improve the patient's quality of life. Understanding how and when to use these medicines involves knowledge of the mechanisms of these drugs as well as familiarity with the literature supporting their efficacy in various patient populations.