Old Problems, New Ideas: I

1
Old Problems, New Ideas I

• G. Michael Allan
• Medical Director, Towards Optimized Practice
• Associate Professor, Family Med, U of A

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Conflict of Interest

• Family Doctor for gt10 yrs
• Academic 7 years
• Pay from U of A and Alberta Health
• Research and Speaking Fees
• Non-Profit Sources (CFPC, CIHR, IHE, ACFP, etc)
• No funding from Industry

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Iron A Plug for Therapy

• Labs for an 80 year old woman with fatigue show
  ongoing iron def anemia (Hgb 101 Ferritin 8).
  This is unchanged for 4 years
• She has no concerning features and a normal scope
  4 years ago. She tells you she cant take her
  iron because of constipation

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Iron A Plug for Therapy

• An RCT recently showed the best treatment for
  iron def (? Hgb but ? side-effects) in the
  elderly was?
• 300 mg of elemental iron daily
• 150 mg of elemental iron daily
• 50 mg of elemental iron daily
• 15 mg of elemental iron daily
• 8 oz steak TID x 6 months

30mg of elemental iron Ferrous sulphate 150mg
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Iron A Plug for Therapy

• 15 mg of elemental iron daily
• RCT of elderly anemic patients
• Hgb ? significantly in anemic groups
• average 14 Hgb points,
• no diff between doses
• Adverse events ? significantly as dose ?
• Dropout ?, NNH 5 for 15mg vs 150mg
• 15mg elemental iron 2.5 mls of Fer-In-Sol

Am J Med 2005 118 1142-7
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Vitamin B12

• You have accepted a new pt into your practice.
  She informs you that she has a long history of
  vitamin B12 deficiency. Her usual practice is to
  see her family physician qmonthly for IM
  injection. She finds these give a good boast of
  energy for her.

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Vitamin B12

• In a recent systematic review of treatment for
  vitamin B12 deficiency what is the best
  management?
• Q monthly injections of 1000ug
• Oral supplementation with 1000-2000ug
• Flintstone Vitamins 12 /day
• Ignore it it wont affect her clinically

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Vitamin B12

• Oral Supplementation or IM Administration
• Systematic review (2 RCTs, total 108 pts, 4mo)
• First study B12 levels in oral group higher at 2
  mo (plt0.001) 4 months
• Second study significant B12 increase in both
  groups (plt0.001)
• Limits Short follow-up (4mo), small numbers,
• Strengths Good clinical question, Oral used
  extensively in some European countries
• Oral supplementation as effective in short term,
  although close follow-up early likely good idea

fam pract 200623279-85
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Tennis Elbow First do

• Mr J. McEnroe (age 42) is in for follow-up. You
  have been seeing him for pain in his right elbow,
  particularly along the lateral epicondyle
• For the last 3 months he tried NSAIDs (Topical
  and oral), splint and physio. He has heard about
  steroid injections but doesnt like the sound of
  them
• He wonders what works

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Tennis Elbow First do

• Which approach may help (and which may harm) Mr.
  McEnroes tennis elbow?
• Glucosamine
• Lateral Epicondyle Steroid Injection
• Continued Physio
• Nitroglycerin
• Night Splint
• Golfing (to balance tendinosis)

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Tennis Elbow First do

• Steroid Injection1
• RCT, 198 pts, 3 arms (injection/physio/usual)
• Results physio lt pain meds
• 6 weeks Injection NNT 8
• 52 wks Injection NNH 4
• Injections ? recurrences poor long term
  outcome
• Patient rating of much improved or complete
  recovery

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Tennis Elbow First do

• Transdermal Nitro2
• Placebo vs ¼ Nitro 5mg/24hr patch (95 elbows)
• Nitro group ? strength ? pain / tenderness
• Asymptomatic ADL (6 mon) AB 21 or NNT 5
• Side-effects frequent (12 quit, NNH8)

1. BMJ 2006333939
2. Am J Sports Med 20033191520
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Hot Flashes

• A 53 year old female is in today for hot flashes.
  She is reluctant to take HRT because she has a
  strong family history of breast cancer.
  Additionally, she has struggled with stress
  incontinence (and you know HRT can worsen that)
• She is wondering about the relative effectiveness
  of non-hormone therapy

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Hot Flashes

• All of the following are effective treatments for
  Hot Flashes, except
• Red Clover
• Gabapentin
• SSRIs
• Clonidine
• Soy Isoflavone Extract

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Hot Flashes

• Red Clover
• Well-designed Meta-analysis of 43 RCTs
• Placebo Red Clover, Methyldopa, Bellergal.
• Things that work
• SSRI/SNRI (mid dose) 1.13 ?Hot Flashes/d (vs
  placebo)
• Clonidine (0.075mg BID) 0.95 - 1.63 ?Hot
  flashes/d
• Gabapentin (300mg TID) 2.05 ?Hot flashes/d
• Soy Isoflavone Extract (50-70mg/d) 0.97-1.22 ?
• Endometrial safety with Isoflavone still
  unresolved.
• Estrogen best (2.5-3 ? Hot flashes/d)

JAMA 2006 295 2057-71.