2020 FMX

Domino Returns With Top 10 Updates for FPs

October 21, 2020, 2:53 pm Michael Devitt — (Editor's note: The study regarding taking hypertension medication at bedtime is under investigation by the editors of the journal in which it was published due to inconsistencies in the data noted by others.) For more than a decade, Frank Domino, M.D., has enlightened Family Medicine Experience attendees with his “Top 10 Updates in Evidence-based Medicine” pesentation — so much so that it has been a main-stage event for four years running.

Domino took the findings as an opportunity for FPs to discuss healthier food choices with parents. “So remind parents that anyone with normal kidneys does not need a sugar-sweetened drink or an electrolyte drink,” Domino said. “They need water.”

Conversely, Domino highlighted studies showing that drinking whole milk instead of reduced-fat milk could reduce the risk of overweight or obesity in children, and watching cooking programs that promote healthy food choices could increase the odds of children choosing healthy snacks.

In other news:

• Early use of antibiotics in childhood could increase the risks for obesity and type 1 diabetes. 
• Combined use of antipyretics and nonsteroidal anti-inflammatory drugs eliminated fevers more effectively than either medication used alone.
• Patients who used opioids after tooth extractions reported significantly higher levels of pain compared with patients who did not. Since previous research has shown that adolescents who are exposed to opioids have a higher risk of opioid dependence as adults, Domino recommended an alternative. “For our young adults and our adolescents, 1,000 mg of acetaminophen plus 600 mg of ibuprofen every six hours together will provide outstanding pain control without the risk of opioids,” he said.

Screening and Prevention

Combined cases of sexually transmitted infections such as chlamydia, gonorrhea and syphilis reached an all-time high in the United States in 2018, according to the CDC.

On the other hand, U.S. teen pregnancy rates decreased by more than 50% between 2008 and 2018, based on information from the Pew Research Center and the CDC. According to Domino, the findings suggested that counseling adolescents on contraceptive use and increasing access to contraceptives lowers teen pregnancy rates.

Elsewhere:

• Domino cautioned FPs about following the American Cancer Society’s recent guideline update on cervical cancer screening for individuals at average risk. “No other organization has endorsed this,” he said, adding, “the take-home here is, don’t start changing your screening yet … just don’t go there yet.”
• Domino drew attention to the June 2020 recommendation from the U.S. Preventive Services Task Force on screening for unhealthy drug use. Although the USPSTF did not extend the screening recommendation to adolescents — and the AAFP has agreed with that stance — Domino thought there was adequate data to screen adolescents as well as adults.  He recommended a tool called CRAFFT, which he uses in practice, as a screening option for this population.

Hypertension

In 2017, the American College of Cardiology and the American Heart Association redefined isolated diastolic hypertension, but recent research indicated that treatment of IDH does not decrease the risk of adverse cardiovascular outcomes in adults. So what should FPs do with these patients? “It’s simple,” Domino said. “Treat them with what we know we do best ― aerobic and resistance exercise, 5% weight loss and salty food restriction.”

“This is probably the most important practice-changing paper that I found this year,” Domino said next, referring to a study that found patients with hypertension who took their medications at bedtime had significantly lower hazard ratios for several cardiovascular events compared with those who took their medications on awakening. Based on the findings, Domino strongly recommended that clinicians explain to their patients the benefits of taking their medications in the evening.

Also of note:

• Clinicians should not treat hypertension in some elderly patients too aggressively.
• Domino said findings from another study show that FPs need to monitor their patients’ alanine aminotransferase and aspartate aminotransferase levels over time. “The bottom line here is that an AST:ALT level (ratio) over 1, or AST and ALT levels that are increasing over time, should make you very concerned about the diagnosis of fatty liver disease,” Domino said, adding that he thought fatty liver disease would become a significant challenge to the health care system in the near future. Nonalcoholic fatty liver disease, Domino continued, should be treated using aggressive weight loss options, including weight loss surgery when necessary.

Food and Drink

There was good news for egg lovers, as research showed that consuming up to one egg per day did not increase cardiovascular disease or stroke risk. “That’s not true,” Domino said of the notion that eggs can increase heart disease risk because of their high cholesterol content. “That hasn’t been true for years. Feel free to go ahead and instruct those patients (that) seven eggs per week is fine.”

While eating eggs may be fine, skipping breakfast is not; people who ate breakfast infrequently or skipped breakfast altogether were more likely to be overweight and have abdominal obesity and to have increased risks for cardiovascular disease and all-cause mortality.

In related news:

• Losing weight can be difficult, particularly for patients with type 2 diabetes, but several types of meal replacements and diets may be effective.
• Some patients may also consider alternate-day fasting, which appears effective in reducing BMI, body fat levels, total cholesterol and waist circumference.

Dementia

Kale, which drew a great deal of attention at Domino’s presentation last year, was also featured in a study on dementia risk. The study found that older individuals with the highest dietary intakes of flavonols from foods such as kale were only about half as likely to develop Alzheimer's dementia as those with the lowest flavonol intake.

On the opposite end of the spectrum, using a standard dose of a single anticholinergic for the equivalent of three years increased the odds for dementia by as much as 49 percent compared with no use.

Meanwhile:

• Compared with nondrinkers, adults who drank alcohol at low to moderate levels appeared to have lower rates of mental status decline, word recall loss and vocabulary loss, and better trajectories of higher cognition scores.

Obesity and Exercise

Not surprisingly, consuming two or more artificially sweetened beverages per day was shown to increase the risks for all-cause mortality, cardiovascular mortality, stroke, increased BMI and obesity, while consumption of one to six artificially sweetened beverages per week increased type 2 diabetes risk.

Also discussed:

• Participating in one to three resistance exercise sessions per week, totaling up to 59 minutes, decreased the risk for total cardiovascular disease events up to 70%, independent of aerobic exercise.
• Walking also has positive effects, with research showing that the more steps a person walks, the lower the risk of all-cause mortality.

COVID-19

Like many FPs, Domino has had first-hand experience with COVID-19. To help during the pandemic, Domino cited observations and best practices pulled from several sources:

• Physical distancing of at least 1 meter decreases the odds of COVID-19 infection by 82%; wearing a face mask decreases the odds of infection by 85%.
• Children and adults ages 10-30 appear to be at the greatest risk of spreading COVID-19. “These are the populations we as health care (professionals) need to focus on with regard to respecting the rules around masks and physical distance,” Domino said.
• Dexamethasone is indicated for patients who are on mechanical ventilation or who require supplemental oxygen but is not recommended for patients with milder cases of the disease.
• Once-daily use of proton pump inhibitors more than doubles the risk of COVID-19 infection and twice-daily PPI use more than triples the risk, compared to not taking PPIs. However, risk of infection is not elevated through use of histamine 2 receptor antagonists.
• Use of famotidine in hospitalized patients has been shown to decrease the risks of intubation and death.
• Vitamin D deficiency appears to increase COVID-19 infection risk, but results from a pilot study indicate that administration of 25-hydroxyvitamin D to hospitalized COVID-19 patients reduces ICU admission and mortality rates.
• Anthony Fauci, M.D., has also reported taking and recommending vitamin D, and Domino recommended that patients take 2,000 to 4,000 IU of vitamin D₃ per day.
• Disconnecting from social media may improve one’s mental health during the pandemic.

Diabetes and Asthma

FPs now have two visual cues to help them determine the risk of new-onset type 2 diabetes in patients. The presence of periodontal disease and missing 15 or more teeth are positively associated with new-onset diabetes, while frequent tooth brushing (three or more times a day) is negatively associated.

More news:

• An umbrella review  examined the effects of SGLT2 inhibitors and GLP1 agonists on cardiovascular outcomes and found that while some raised the risk of cardiovascular disease, most showed benefit. Domino said that although metformin is currently the drug of choice for patients with newly diagnosed diabetes, “These drugs are likely going to become first-line agents, especially in those who are at higher risk for cardiovascular outcomes.”
• A randomized controlled trial of patients with mild persistent asthma found no significant differences between a combination of budesonide and formoterol taken as needed and budesonide maintenance therapy plus an as-needed rescue inhaler with regard to the rate of severe asthma exacerbations and adverse events.

Diagnosing ACL Tears

Finally, with many high schools and colleges resuming their sports programs, Domino provided a link and a video showing the use of the Lever sign to diagnose acute anterior cruciate ligament tears. He noted that the Lever sign has higher sensitivity and specificity than the anterior drawer and may be easier for some FPs to perform than the Lachman test.

“It’s not perfect, but it’s pretty good and it’s probably much better in the acute swelling stage of an ACL tear,” Domino said.  “It’ll probably provide better patient comfort and better diagnostic ability on your part.”