NEJM Journal Watch Guideline Watch 2021 PDF

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Summaries and highlights of the most important new clinical guidelines to inform your practice

Guideline Watch 2021

September 2021

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Dear Reader, Clinical guidelines are used increasingly to set practice standards and quality measures. NEJM Journal Watch not only publishes summaries of the latest clinical research, but also helps you to keep up with the guidelines most important to general medical practice. Our physician-editors regularly survey a broad range of medical journals to identify practice guidelines from a variety of disciplines. They choose recommendations with the most clinical impact and highlight key points, pointing out what’s new and what remains unchanged. This collection of Guideline Watches is of broad relevance to clinical practice, spanning outpatient and inpatient medicine and addressing both primary care and subspecialty perspectives. We hope you enjoy this compilation and find it useful for providing the best and most responsible patient care. Allan S. Brett, MD NEJM Journal Watch Editor-in-Chief

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Guideline Watch 2021

Table of Contents Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients

4

Perioperative Management of Endocrine and Urologic Medications

5

Clostridioides difficile Infection: Updated Recommendations

7

Managing Acute Upper Gastrointestinal Bleeding from Ulcers

9

Practical Approach to Identifying and Managing Idiosyncratic Drug-Induced Liver Injury

11

Updated Recommendations for Colorectal Cancer Screening

12

Screening for Vitamin D Deficiency in Community-Dwelling, Nonpregnant Adults

14

A Consensus Decision Pathway for Optimizing Care for Heart Failure

15

ACP Recommends Short-Course Antibiotics for Many Common Infections

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Managing Acute Diverticulitis

19

Providing Long-Term Oxygen Therapy for Patients with COPD and Interstitial Lung Disease

20

Contrast-Enhanced MRIs in Patients with Kidney Disease

21

2020 Asthma Guideline Update

22

NEJM Journal Watch is produced by NEJM Group, a division of the Massachusetts Medical Society. ©2021 Massachusetts Medical Society. All rights reserved.

Guideline Watch 2021

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Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients High-flow nasal cannulae generally should be used in hypoxemic patients. Patricia Kritek, MD, reviewing Ann Intern Med 2021 Apr 27.

Sponsoring Organization: American College of Physicians (ACP) Background This is the first guideline focused solely on use of high-flow nasal cannulae (HFNC). Recommendations were based on best available evidence as well as patient values and preferences, potential risks and benefits, and cost. Key Points • Patients with hypoxemic respiratory failure should be treated initially with HFNC as opposed to noninvasive ventilation (NIV).

• Patients with postextubation hypoxemia should be treated with HFNC as opposed to conventional oxygen therapy. COMMENT

Use of HFNC to support hypoxemic patients has increased dramatically in the past decade, but guidance on when it is the best option and when it should be avoided has been minimal. Although the evidence of benefit is low quality, using HFNC as a first step in managing hypoxemic respiratory failure makes sense: It is less expensive than NIV and generally is well tolerated. Data suggest lower short-term mortality and less progression to intubation with HFNC than with NIV. The recommendation for postextubation support is reasonable but is a conditional recommendation because of the paucity of data.

Qaseem A et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of acute respiratory failure: A clinical guideline from the American College of Physicians. Ann Intern Med 2021 Apr 27; [e-pub]. (https://doi.org/10.7326/M20-7533) Baldomero AK et al. Effectiveness and harms of high-flow nasal oxygen for acute respiratory failure: An evidence report for a clinical guideline by the American College of Physicians. Ann Intern Med 2021 Apr 27; [e-pub]. (https://doi.org/10.7326/M20-4675) Dr. Kritek is Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of Washington, Seattle.

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Perioperative Management of Endocrine and Urologic Medications A multidisciplinary group has published recommendations on which drugs to continue and which to hold before surgery. Allan S. Brett, MD, reviewing Mayo Clin Proc 2021 Jun.

Sponsoring Organization: Society for Perioperative Assessment and Quality Improvement (SPAQI) Background SPAQI is a multidisciplinary organization that recently has published several position papers on perioperative medication management. This statement — addressing endocrine and urologic medications — was produced by a consensus process outlined by the authors. Key Recommendations

Diabetes drugs: • Basal (intermediate- or long-acting) insulins generally should be continued at 60% to 80% of the usual dose on the morning of surgery or the evening before surgery, depending on the patient’s usual insulin schedule. • Metformin, sulfonylureas, pioglitazone, and dipeptidyl peptidase (DPP)-4 inhibitors should not be given the morning of surgery. • Sodium–glucose cotransporter (SGLT)-2 inhibitors should be stopped at least 3 days before surgery. • Glucagon-like peptide (GLP)-1 agonists should be held the morning of surgery (for agents dosed daily) or during the week before surgery (for agents dosed weekly). Other endocrine drugs: • Thyroid hormone and antithyroid drugs can be taken the morning of surgery. • A patient’s usual dose of corticosteroid can be taken the morning of surgery (this document did not address perioperative administration of additional, stress-dose steroids). • Most other hormonal or endocrine-related drugs can be continued the morning of surgery. However, bisphosphonates should be held (given risk for esophagitis when patients are supine after taking these drugs). Urologic drugs: • α-blockers and 5-α-reductase inhibitors can be taken the morning of surgery. • Anticholinergic bladder medications should be held the morning of surgery. • Phosphodiesterase (PDE)-5 inhibitors, when prescribed for urologic indications, should be held for 3 days prior to surgery, due to concern about intraoperative hypotension.

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COMMENT

Most of these recommendations are based on common-sense inferences from these drugs’ mechanisms of action and side effects — not on direct perioperative studies. The authors encourage clinical judgment in certain scenarios (e.g., holding certain prothrombotic hormonal agents in patients at high risk for perioperative thrombosis). I would urge clinicians who perform preoperative assessments to read this report.

Pfeifer KJ et al. Preoperative management of endocrine, hormonal, and urologic medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement. Mayo Clin Proc 2021 Jun; 96:1655. (https://doi.org/10.1016/ j.mayocp.2020.10.002) Dr. Brett is Clinical Professor of Medicine at the University of Colorado School of Medicine.

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Clostridioides difficile Infection: Updated Recommendations Diagnosis and treatment are discussed, with substantial detail on fecal microbiota transplantation. David J. Bjorkman, MD, MSPH (HSA), SM (Epid.), reviewing Am J Gastroenterol 2021 Jun.

Sponsoring Organization: American College of Gastroenterology Background This clinically oriented document is meant to complement the Infectious Diseases Society of America’s 2018 guideline on Clostridioides difficile infections (NEJM JW Infect Dis May 2018 and Clin Infect Dis 2018; 66:e1). The authors rate each recommendation as strong or conditional, and they grade the quality of supporting evidence as high, moderate, or low. Selected Recommendations • A two-step diagnostic testing algorithm is favored: Start with a sensitive test for C. difficile infection (CDI), and when results are positive, perform specific testing for toxin.

• Oral vancomycin or fidaxomicin generally is favored for treating patients with nonsevere CDI, but metronidazole is acceptable for low-risk patients — especially when cost is a factor. • Patients with severe CDI should be treated with either oral vancomycin or fidaxomicin (but not metronidazole). Severe disease is defined as having a leukocytosis >15,000 white blood cells/mm3 or a creatinine level of >1.5 mg/dL. • Fulminant CDI (defined as severe CDI plus hypotension, shock, ileus, or megacolon) should be managed with fluid resuscitation and high-dose oral vancomycin; addition of parenteral metronidazole and vancomycin enemas (for patients with ileus) can be considered. • Fecal microbiota transplantation (FMT) should be considered for refractory or severe CDI. • A first recurrence should be treated with tapering/pulsed-dose vancomycin or fidaxomicin if it was not the initial therapy. A patient experiencing a second or further recurrence of CDI should be treated with FMT, delivered via a colonoscope or capsules, with enemas used when colonoscopy or capsules are not available. Repeat FMT can be used to treat a recurrence within 8 weeks of initial FMT. • Patients with recurrent CDI who are not FMT candidates or have relapsed after FMT can be given long-term oral vancomycin prophylaxis to prevent recurrences. Oral vancomycin prophylaxis also can be considered when patients with recurrent CDI are given systemic antibiotics. • Additional recommendations are made for specific populations (those with inflammatory bowel disease, pregnancy, lactation, or immunocompromise) and for surgical intervention. • Probiotics should not be used for primary or secondary prevention of CDI.

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COMMENT

The narrative discussions for each recommendation are well written, with balanced assessments of the strengths and limitations of supporting evidence. Overall, this document provides comprehensive updated guidance on managing CDI. Note: The Infectious Diseases Society of America currently is updating its guideline on C. difficile and will be recommending fidaxomicin as first-line treatment for a patient with an initial episode of C. difficile infection. However, the recommendation is “conditional” and acknowledges vancomycin as an acceptable alternative.

Kelly CR et al. Prevention, diagnosis, and treatment of Clostridioides difficile infections. Am J Gastroenterol 2021 Jun; 116:1124. (https://doi.org/10.14309/ajg.0000000000001278) Dr. Bjorkman is Professor in the Division of Gastroenterology, Hepatology and Nutrition at the University of Utah School of Medicine.

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Managing Acute Upper Gastrointestinal Bleeding from Ulcers An American College of Gastroenterology guideline addresses risk stratification, endoscopic intervention, proton-pump inhibitors, and transfusions. David J. Bjorkman, MD, MSPH (HSA), SM (Epid.), reviewing Am J Gastroenterol 2021 May 1.

Sponsoring Organization: American College of Gastroenterology (ACG) Background Acute upper gastrointestinal bleeding is the most common gastrointestinal cause of hospitalization in the U.S. To reconcile multiple recently published guidelines, ACG-sponsored reviewers assessed primary studies and made recommendations according to the strength of the supporting evidence. They addressed only bleeding from peptic ulcers. Key Points Strong recommendations, backed by moderate- or high-quality evidence:

• Endoscopic therapy should be performed for ulcers with active bleeding or a nonbleeding visible vessel. • High-dose proton-pump inhibitor (PPI) therapy should be given continuously (intravenously) or intermittently (intravenously or orally) for 3 days after successful endoscopic therapy. Conditional recommendations, with low- or very low–quality evidence: • Early risk stratification should be performed in the emergency department, and patients with low risk (Glasgow-Blatchford score, 0–1) should be discharged for outpatient follow-up. • Blood transfusions should be restrictive (i.e., only for patients with hemoglobin levels ≤7 g/dL). • Erythromycin infusion should be given before endoscopy. • Endoscopy should occur within 24 hours of hospitalization. • Endoscopic treatment should be undertaken for high-risk ulcers. • Epinephrine injection should not be used alone — only in combination with another hemostatic modality. • Twice-daily oral PPI therapy should be continued for 2 weeks after index endoscopy and parenteral PPI treatment. • Patients with recurrent bleeding should undergo another endoscopy procedure, rather than surgery or embolization; however, patients in whom endoscopic therapy fails should proceed to embolization.

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COMMENT

The supporting literature review explains the nuances of the recommendations. Note that no agreement could be reached on the need for endoscopic therapy for ulcers with adherent clots or for use of PPIs prior to endoscopy. The literature supports neither of these actions, but therapy often is individualized, based on perceived risk for rebleeding. The role of endoscopic therapy and parenteral PPI therapy in patients with high-risk ulcers is strong, but the other recommendations are conditional, based on low-quality evidence. Nonetheless, this guideline should be the current standard of care for patients with ulcer-related acute upper gastrointestinal bleeding.

Laine L et al. ACG clinical guideline: Upper gastrointestinal and ulcer bleeding. Am J Gastroenterol 2021 May 1; 116:899. (https://doi.org/10.14309/ajg.0000000000001245) Dr. Bjorkman is Professor in the Division of Gastroenterology, Hepatology and Nutrition at the University of Utah School of Medicine.

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Practical Approach to Identifying and Managing Idiosyncratic Drug-Induced Liver Injury The American College of Gastroenterology has updated its 2014 practice guideline. Atif Zaman, MD, MPH, reviewing Am J Gastroenterol 2021 May 1.

Sponsoring Organization: American College of Gastroenterology Background Drug-induced liver injury (DILI) can be separated into two categories: Intrinsic type, where a drug can cause injury in a predictable fashion (e.g., acetaminophen), and idiosyncratic type, where injury is less predictable. The focus of this guideline is the idiosyncratic type, often associated with commonly used antimicrobials, oncologic agents, dietary supplements, and herbal supplements. Key Points • Liver biopsy should be considered when immunosuppressive therapy is being contemplated, liver enzymes rise despite discontinuing the suspected offending agent, or delayed resolution of liver enzyme elevation is noted. Liver biopsy also should be considered when autoimmune hepatitis is a possibility: DILI can present with features similar to those of autoimmune hepatitis, and non–drug-related autoimmune hepatitis and DILI can present similarly.

• Prognostic models such as the Model for End-stage Liver Disease (MELD) and the Charlson comorbidity index (CCI) can be useful to predict 6-month mortality. Clinicians might find the web-based DILI mortality calculator useful. • Although no good evidence supports or refutes use of corticosteroids, steroids might be appropriate for patients in whom autoimmune hepatitis is highly suspected. • N-acetylcysteine can be considered for DILI patients in whom progression to acute liver failure is likely.

COMMENT

As with the previous guidelines on DILI, the overall quality of evidence in this updated practice guidance is of low quality. These guidelines should be viewed as preferred approaches and are intended to be flexible enough to be adjusted to particular clinical situations. Patients with severe DILI and concern for impending acute liver failure should be managed in a tertiary center.

Chalasani NP et al. ACG clinical guideline: Diagnosis and management of idiosyncratic drug-induced liver injury. Am J Gastroenterol 2021 May 1; 116:878. (https://doi.org/10.14309/ajg.0000000000001259) Dr. Zaman is Professor in the Department of Gastroenterology and Hepatology at Oregon Health & Science University.

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Updated Recommendations for Colorectal Cancer Screening The U.S. Preventive Services Task Force concludes, with moderate certainty, that screening confers moderate benefit to average-risk patients starting at age 45. Thomas L. Schwenk, MD, reviewing JAMA 2021 May 18.

Sponsoring Organization: U.S. Preventive Services Task Force (USPSTF) Background The USPSTF last published colorectal cancer (CRC) screening guidelines for average-risk patients in 2016 (NEJM JW Gen Med Aug 1 2016 and JAMA 2016; 315:2564). They have now updated those recommendations and added a new recommendation for younger people (age range, 45–49). These guidelines apply to adults (age, ≥45) at average risk for colorectal cancer (i.e., no prior CRC, adenomatous polyps, or inflammatory bowel disease; no prior diagnosis or family history of genetic predisposition to CRC, such as Lynch syndrome). Key Recommendations • The Task Force concludes with high certainty that CRC screening for middle-aged people (age range, 50–75) confers substantial benefit (A Recommendation).

• The USPSTF concludes with moderate certainty that screening younger people (age range, 45–49) confers moderate benefit (B Recommendation). • The Task Force concludes with moderate certainty that screening older people (age range, 76–85) who have been screened previously confers small benefit (C Recommendation). People in this age range who have never been screened might benefit slightly more. • Evidence for benefit in even older patients (age, ≥86) is lacking, but harms of screening likely outweigh any long-term survival benefit. What’s Changed The main change in this recommendation is the lower age (45) for beginning screening. The Task Force took a broad view of available tests and included both direct visualization (i.e., computed tomography [CT] colonography, colonoscopy, and flexible sigmoidoscopy) and stool-based tests (i.e., high-sensitivity guaiac fecal occult blood tests [gFOBT], fecal immunochemical tests [FIT], and stool DNA tests). The only stool DNA test currently approved by the U.S. FDA includes a FIT component (sDNA-FIT). Based on a sophisticated modeling exercise to balance harms and benefits that accompanied the Task Force’s evidence assessment and recommendation, they recommend the following intervals for screening:

• gFOBT or FIT: every year • sDNA-FIT: every 1 to 3 years • CT colonography: every 5 years • Flexible sigmoidoscopy: every 5 years, or every 10 years with FIT every year • Colonoscopy: every 10 years The Task Force did not recommend any particular test as most desirable or effective.

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