IN THIS ISSUE
MAKING DECISIONS IN PRIMARY CARE--TREATMENTS
These treatments may not be necessary and could even be harmful; do not recommend them without considering the risk and likely benefit (5).
Long-term acid suppression therapy (proton pump inhibitors (PPIs) or histamine-2 receptor antagonists) for treatment of patients with gastroesophageal reflux disease (GERD) that is not titrated to the lowest effective dose for adequate symptom control (13).
Use the lowest dose needed for adequate symptom management. High-dose prescription PPIs and use of PPIs for more than 1 year may increase fracture risk, and long-term use of PPIs may cause low serum magnesium levels (17,18). Aside from recurrence of symptoms, the risk associated with reducing or stopping therapy appears to be minimal. Data suggest that, for patients with GERD, rates of progression to erosive esophagitis and Barrett's esophagus are relatively low over a 20-year period.
Cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment (16) (Resources--Cancer).
Cancer-directed treatments are likely to be ineffective for solid tumor patients who meet the above criteria. Exceptions include patients with a low performance status due to other conditions or those with disease characteristics (eg, mutations) that suggest they will respond well to therapy. Primary care physicians should counsel patients on the low likelihood of the therapy's effectiveness for them and ensure they have access to palliative and supportive care.
Renal system (15)
Chronic dialysis for older adults with a high burden of comorbidity that does not include a shared decision-making process among patients, their families, and their physicians about the patient's goals and prognosis and the expected benefits of treatment.
Limited observational data suggest that survival may not differ substantially for older adults with a high burden of comorbidity who initiate chronic dialysis versus those managed conservatively. Elicit the patient's goals and preferences, and explain the prognosis and expected benefits and harms of dialysis. Primary care physicians should counsel patients on the low likelihood of the effectiveness of dialysis for them and ensure they have access to palliative and supportive care.
Peripherally inserted central catheters (PICC) in stage III-V chronic kidney disease (CKD) patients without consultation with nephrology.
Venous preservation is critical for stage III-V CKD patients. Arteriovenous fistulas (AVF) for hemodialysis access have fewer complications and lower patient mortality than grafts or catheters. Excessive venous puncture damages veins, destroying potential AVF sites. Early nephrology consultation increases AVF use at hemodialysis initiation and may avoid unnecessary PICC lines or central/peripheral vein puncture, which can cause VTE and central vein stenosis.
Erythropoiesis-stimulating agents (ESAs) for CKD patients with hemoglobin levels ≥10 g/dL without symptoms of anemia.
ESAs have been linked to increased risk of cardiovascular events in patients with chronic kidney disease. Discuss the risks with patients, and if prescribing ESAs, set relatively conservative targets for hemoglobin levels (9-11 g/dL).
Nonsteroidal anti-inflammatory drugs (NSAIDs) in individuals with hypertension, heart failure, or CKD of all causes, including diabetes.
The use of NSAIDs, including cyclo-oxygenase type 2 (COX-2) inhibitors, for the pharmacologic treatment of musculoskeletal pain can elevate blood pressure, make antihypertensive drugs less effective, cause fluid retention, and worsen kidney function in these individuals. Other agents such as acetaminophen, tramadol, or short-term use of narcotic analgesics may be safer than and as effective as NSAIDs.
Use of antibiotics in cases of acute, mild, uncomplicated sinusitis (7,8).
Only 0.5% to 2% of acute viral sinus infections progress to bacterial infections. Most acute rhinosinusitis resolves without treatment in 2 weeks. A decision to treat should be made based on symptoms of discolored nasal secretions and facial or dental tenderness when touched (Resources--Antibiotics). Amoxicillin-clavulanate should be first-line antibiotic treatment for most acute rhinosinusitis.