Steroids for pharyngitis?

- Jennifer Middleton, MD, MPH

This month, The Journal of Family Practice (JFP) published a review of a recent Cochrane meta-analysis regarding the use of steroids for patients with "exudative or severe sore throat." The Cochrane researchers found that even one dose of a corticosteroid (either dexamethasone PO, dexamethasone IM, or prednisone PO) increased the number of patients who reported resolution of pain in twenty-four hours (number needed to treat [NNT] = 4).  The Cochrane researchers included studies of patients with both viral and bacterial pharyngitis.

Despite evidence-based tools such as the modified Centor score, which can determine the pre-test probability of streptococcal pharyngitis and guide treatment (described nicely in this AFP article), physicians still overprescribe antibiotics for upper respiratory infections, including pharyngitis.  This AFP by Topic on Upper Respiratory Infections provides a useful review of current treatment guidelines for these prevalent conditions; several articles in that grouping advise caution regarding overuse of antibiotics.  It may be that patients with painful pharyngitis don't necessarily want antibiotics, though, but just something to control their pain.  This new Cochrane meta-analysis, with that excellent NNT regarding improvement of pain after only one day of treatment with a steroid, suggests that steroids may be another useful tool in our pharyngitis treatment kit.

The JFP reviewers are quick to point out that these corticosteroids weren't used alone; the studies in the meta-analysis used them in addition to either antibiotics or analgesics.  Hopefully we will see some randomized controlled trials (RCTs) in the next few years that determine whether steroids are useful by themselves for patients not needing an antibiotic. In the meantime, since the RCTs in the Cochrane meta-analysis used varying methods, we don't have a clear guideline about which patients might benefit or what dose and administration route of corticosteroid to use.

Do you already prescribe steroids for patients with severe pharyngitis (viral or bacterial)?  If not, would this Cochrane meta-analysis encourage you to try it?

Medicating mild hypertension: is more evidence needed?

- Kenny Lin, MD, MPH

In the July 1st issue of American Family Physician, Dr. Janelle Guirguis-Blake commented on a Cochrane Review that found no benefits from pharmacotherapy for mild hypertension (systolic blood pressure of 140 to 159 mm Hg and/or diastolic blood pressure of 90 to 99 mm Hg) on cardiovascular outcomes or mortality. However, the randomized trials' relatively small number of participants (fewer than 9000) and short follow-up periods (five years or less) left open the possibility that a significant benefit could still exist. Therefore, Dr. Guirguis-Blake concluded: "Larger double-blinded RCTs in this population of patients with stage 1 hypertension are needed to clarify the potential long-term benefits of pharmacologic therapy."

When existing research does not adequately answer an important clinical question - in this case, are medications superior to lifestyle modifications or no treatment for mild hypertension? - researchers invariably recommend collecting more evidence. But is performing a large randomized trial of mild hypertension management feasible, given that the standard of care set in 2003 by the Seventh Report of the Joint National Committee (JNC-7) (and reflected in this AFP Point-of-Care Guide) is to routinely identify and treat blood pressures in this range? The U.S. Preventive Services Task Force apparently thinks so; after previously declaring that the benefits of screening were "well established," the USPSTF has released an extensive draft research plan to reevaluate benefits, harms, best methods, and recommended intervals for screening for high blood pressure in adults.

With the next USPSTF statement at least a few years down the road, current evidence-based guidance on hypertension management is limited. The U.S. National Heart, Lung, and Blood Institute, which convened the previous JNC panels, recently announced in a cardiology journal its intention to stop producing guidelines. Instead, it says it will partner with outside medical groups to release its long-delayed JNC-8 hypertension guideline. Since guidelines sponsored by subspecialty societies are less likely to adhere to Institute of Medicine standards for producing unbiased guidelines, family physicians and other primary care clinicians should advocate for their organizations to participate in this process.

Another strike against NSAIDs?

- Jennifer L. Middleton MD, MPH

One of the issues family docs deal with on a daily basis is pain control.   I usually think about pain medication as falling into one of three categories: acetaminophen, NSAIDs, and opioids.  I frequently recommend acetaminophen, but patients often tell me "it's not strong enough for me" (maybe an unintentional consequence of those commercials touting Tylenol's gentleness?).  And, of course, I defer opioid regimens if possible given the risks of addiction and diversion.

Perhaps you've already heard about The Lancet's NSAID meta-analysis article from about a month ago.   The authors performed a robust literature search and included hundreds of trials with several outcome measures, one of which was the rate of "major coronary events" (a composite of non-fatal myocardial infarction and coronary death).  The authors found that long-term use of all non-steroidal anti-inflammatory drugs (NSAIDs), selective COX-2 or non-selective, doubled the risk of heart failure.  I'd like to focus on two non-selective NSAIDs, ibuprofen and naproxen, for the rest of this post.

I found this meta-analysis unsettling, as I like having an option in between acetaminophen and opioids to offer my patients.  True, the authors only examined patients taking high dose NSAIDs (2400 mg ibuprofen/day and 1000 mg naproxen/day) for at least 4 weeks.  Is it safe, then, to extrapolate that lower doses and/or shorter periods of time are safer?

AFP had a nice article about osteoarthritis treatment last year that discussed the pros and cons of all of these medication classes. Rereading that article this past week reminded me that every 12th patient taking an NSAID, even short-term, will experience a gastrointestinal (GI) bleed, kidney problem, or elevated blood pressure (number needed to harm [NNH] = 12 for that composite outcome).  As NNHs go, that's a pretty impressive number.

For now, at least, NSAIDs probably should be off the table for patients at an increased risk of heart disease.  Myself, I will probably continue recommending NSAIDs in patients without a history of GI bleed, with normal kidney function, and without a history of heart disease, but I will recommend more modest doses and shorter periods of use.  I will probably spend more time counseling patients, too, about the risks of ibuprofen and naproxen.

I encourage you to take a look at these related AFP By Topic collections:
Heart Failure
Pain: Chronic 
Arthritis and Joint Pain (includes this AHRQ-EHC review's discussion of NSAID risks)

How frequently have you been recommending NSAIDs?  Will this meta-analysis change your NSAID prescribing?

Social media guidance for family physicians

- Kenny Lin, MD, MPH

How do you use social media for professional purposes? An increasing number of family physicians use channels such as blogs, Facebook, and Twitter to keep up with the medical literature, network with other health professionals, and provide health education to current and prospective patients and their communities. When AFP launched its Community Blog and Facebook and Twitter accounts in 2010, there was little published guidance for physicians on how to get started in social media. Guidelines from the American Medical Association focused on avoiding unprofessional behavior, while the American Academy of Pediatrics reviewed the risks of social media use in children and adolescents, including cyberbullying and sexting. The author of a 2011 Curbside Consultation on whether physicians should be "friends" with their patients on social networking websites remarked: "In terms of universally accepted standards for interacting with patients using social media, it is kind of like the Wild West."

The Wild West got a little bit tamer last week, when the American Academy of Family Physicians released "Social Media for Family Physicians: Guidelines and Resources for Success." Designed to meet the needs of family physicians with varying levels of social media experience, this 15-page document offers a valuable road map that includes a concise orientation to major social media channels; a suggested initial approach; guidance on protecting patient privacy; and commonsense recommendations for social media policies in private and employed physician practices.

USPSTF: Diet and exercise counseling not routinely recommended for healthy adults

- Jennifer Middleton, MD, MPH

I was surprised to come across the United States Preventive Services Task Force (USPSTF) update in the June 15 AFP this weekend regarding nutrition and physical activity counseling for healthy adults:

[E]xisting evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet and physical activity is small. 

And, they listed a potential harm to providing this counseling:

Harms may include the lost opportunity to provide other services that have a greater health effect.

As a family physician, I want to help my patients to live the best lives they can, and I feel strongly that good nutrition and exercise are both critical to doing so.  So, this is a difficult USPSTF recommendation for me to absorb.

Of course, to clarify, the USPSTF only said that counseling regarding these matters is not effective. They did not make any value statements about diet and exercise.  But given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective?  Is it that we just don't counsel well?  Or, is something more than just counseling necessary to effect behavior change?

A review article from 1999 and a more recent systematic review suggest that individual, computerized nutrition counseling may result in positive changes. Telephone interventions may also be effective for improving nutrition and exercise habits.  Targeting counseling about nutrition that focuses on two concepts from health behavior theory, self-efficacy ("I believe I have what I need to make the change") and outcome expectations ("Making this change will result in a good outcome") also can make a difference. 

Perhaps we need to both 1) make our counseling more effective, and 2) employ a more interdisciplinary approach to help our patients make sustainable changes.

This AFP USPSTF update is included in the AFP By Topic for Health Maintenance and Counseling.  There is a lot of nice information there about health counseling in general (I especially like this Family Practice Management article on motivational interviewing).

Will this USPSTF update change your approach to diet and exercise counseling in the office?

Rosiglitazone for diabetes: helpful, harmful, or neither?

- Kenny Lin, MD, MPH

Last week, an advisory panel convened by the U.S. Food and Drug Administration (FDA) voted to relax safety restrictions on the diabetes drug rosiglitazone (Avandia) that were put in place in response to previous evidence that rosiglitazone may increase the risk of heart attacks and cardiovascular deaths. American Family Physician first highlighted these safety concerns in its March 15, 2008 Tips From Other Journals, which Dr. Kenneth Moon concluded:

There is substantial circumstantial evidence that rosiglitazone is associated with higher risks of heart failure and myocardial infarction. Despite the awkwardness of persuading a patient to use a drug that may provide similar benefits but pose greater risks than other proven agents, the legitimate concerns raised by these studies make this a serious issue. Until there is conclusive evidence about the safety of rosiglitazone, many physicians and their patients may be more comfortable using alternative treatments.

Subsequent AFP articles on management of blood glucose in type 2 diabetes and rosiglitazone vs. pioglitazone reinforced cautionary messages about rosiglitazone. However, the results of a large randomized trial published in 2009 found similar risks for cardiovascular hospitalizations and death in patients using rosiglitazone compared to patients taking other oral diabetes drugs. This trial, which was sponsored by rosiglitazone's manufacturer GlaxoSmithKline, was criticized for methodological problems, but an independent re-analysis of the trial's data persuaded the FDA advisory panel that the drug's safety risks had been exaggerated in previous studies.

If the FDA acts on the advisory panel's recommendations and makes rosiglitazone more widely available, should family physicians prescribe it? It is worth noting that the panel considered only the drug's safety, not its effectiveness. A previous AFP Journal Club reminded readers that the disease-oriented outcome of improved glycemic control does not necessarily lead to patients living longer or better. Rosiglitazone causes more weight gain and congestive heart failure than metformin, and is more expensive than metformin and sulfonylureas. For those reasons, it should be a second- or third-line drug choice for patients with type 2 diabetes.

The safety risks of backyard trampolines

- Jennifer Middleton, MD, MPH

I've been watching trampolines sprout up in backyards all over our neighborhood this spring, and seeing them has resurrected some memories from residency.  Like many family physicians, I spent time in a children's emergency department (ED) as a resident.

What I saw during my rotation made me wonder about the safety of these bouncy backyard devices.  I saw an injury related to backyard trampolines during nearly every shift that summer.  These children typically either fell off the trampoline onto the ground or got caught in the gap between the mat and the metal support.  Some of these injuries were just contusions and sprains, but I also helped evaluate several broken bones and a couple of head injuries.

It turns out that my ED experiences were not atypical.  The American Academy of Pediatrics (AAP) has been advising against recreational backyard trampoline use since 1977, with their most recent update last fall. (1)  Similarly, the American Academy of Orthopedic Surgeons also has a position statement against backyard trampoline use. (2) Despite these recommendations, trampoline use and trampoline injuries in the US are on the rise, from an average of about 41,000/year in the early 1990s to about 88,000/year in the early 2000s. (3) More children are injured directly on the mat, though around a third of injuries are from falls to the ground. (4,5)

I could find no rigorous evidence base to demonstrate that counseling against backyard trampoline use reduces injuries, but at least one literature review suggests that physician counseling about other childhood safety issues does reduce injuries. (6)  And, here's a recent AFP article about unintentional childhood injury prevention: http://www.aafp.org/afp/2013/0401/p502.html.  

My suspicion is that many parents remain unaware of these dangers (perhaps like this mother was), and a brief question about trampoline use would be a simple addition to our safety counseling at well child visits.

Is this topic worth discussing with families in the office?  I welcome your thoughts.


(1) Trampoline Safety in Childhood and Adolescence.  Council on Sports Medicine and Fitness.  Pediatrics; originally published online September 24, 2012. http://pediatrics.aappublications.org/content/early/2012/09/19/peds.2012-2082.full.pdf+html
(2) http://www.aaos.org/about/papers/position/1135.asp
(3) Linakis et al. Emergency department visits for pediatric trampoline-related injuries: an update. Acad Emerg Med. 2007 Jun;14(6):539-44. Epub 2007 Apr 20. http://www.ncbi.nlm.nih.gov/pubmed/17449791
(4) Black and Amadeo. Orthopedic injuries associated with trampoline use in children. Can J Surg. 2003 June; 46(3): 199–201.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211739/
(5) McDermitt, Quinlin, Kelly. Trampoline injuries in children. J Bone Joint Surg Br. 2006 Jun;88(6):796-8. http://www.ncbi.nlm.nih.gov/pubmed/16720776
(6) Bass et al. Childhood injury prevention counseling in primary care settings: a critical review of the literature. Pediatrics. 1993 Oct;92(4):544-50. http://www.ncbi.nlm.nih.gov/pubmed/8414825