Joel J. Heidelbaugh

American Gastroenterological Association Institute Technical Review on the Use of Thiopurines, Methotrexate, and Anti–TNF-α Biologic Drugs for the Induction and Maintenance of Remission in Inflammatory Crohn's Disease

Abbreviations used in this paper: ACG, American College of Gastroenterology; ADA, adalimumab; AZA, azathioprine; BSG, British Society of Gastroenterology; CD, Crohn’s disease; CDAI, Crohn’s Disease Activity Index; CI, confidence interval; CZP, certolizumab pegol; ECCO, European Crohn’s and Colitis Organisation; GRADE, Grading of Recommendations Assessment, Development and Evaluation; HR, hazard ratio; IBD, inflammatory bowel disease; IFX, infliximab; 6-MP, 6-mercaptopurine; MTX, methotrexate; OR, odds ratio; PICO, population, intervention, comparator, and outcome; RCT, randomized controlled trial; RR, relative risk; SIR, standardized incidence ratio; TNF, tumor necrosis factor.

American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Lynch Syndrome

Veterans Affairs Center for Clinical Management Research; Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Division of Gastroenterology, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada; Departments of Family Medicine and Urology, University of Michigan Medical School, Ann Arbor, Michigan; and Division of Gastroenterology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada

Proton pump inhibitors and risk of vitamin and mineral deficiency: evidence and clinical implications

Proton pump inhibitors (PPIs) remain the superior choice worldwide in antisecretory therapy in the evidence-based treatment of upper gastrointestinal disorders including gastroesophageal reflux disease, erosive esophagitis, dyspepsia and peptic ulcer disease. PPI overutilization in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. Nonjudicious use of PPIs creates both preventable financial as well as medical concerns. PPIs have been associated with an increased risk of vitamin and mineral deficiencies impacting vitamin B12, vitamin C, calcium, iron and magnesium metabolism. While these risks are considered to be relatively low in the general population, they may be notable in elderly and malnourished patients, as well as those on chronic hemodialysis and concomitant PPI therapy. No current evidence recommends routine screening or supplementation for these potential vitamin and mineral deficiencies in patients on either short- or long-term PPI therapy. Reducing inappropriate prescribing of PPIs can minimize the potential risk of vitamin and mineral deficiencies.

American Gastroenterological Association Institute Guideline on the Pharmacological Management of Irritable Bowel Syndrome

Fox Chase Cancer Center, Philadelphia, Pennsylvania; VA Tennessee Valley Healthcare System, Vanderbilt University, Nashville, Tennessee; University of Michigan Ann Arbor, Michigan; Department of Veterans Affairs Medical Center, Gastroenterology Section, North Florida/South Georgia Veterans Health System, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida; and Minneapolis Veterans Affairs Health System, University of Minnesota, Minneapolis, Minnesota

Proton pump inhibitors: are they overutilised in clinical practice and do they pose significant risk?

Proton pump inhibitors are highly effective acid suppressants with decades of use highlighting positive outcomes in millions of patients worldwide, and they offer minimal risk of adverse events. PPIs are considered overutilised when prescribed without an appropriate indication, when patients are left on them ‘indefinitely’ without appropriate indications and when they are continued after being utilised for most cases of hospital SUP. While several adverse outcomes have been linked to PPI therapy, most data are from retrospective observational studies that may be subject to confounding and bias.

Adverse effects of testosterone replacement therapy: an update on the evidence and controversy

Testosterone replacement therapy (TRT) has been used in millions of men worldwide to treat diminished libido and erectile dysfunction, and to improve strength and physical function. The estimated likelihood of adverse effects of long-term TRT is still essentially unknown, as overall high-quality evidence based upon prospective randomized trials to recommend for or against its use in most men with testosterone deficiency (TD) is lacking. Evidence to suggest that TRT increases cardiovascular morbidity and mortality risks is poor, as results vary across study populations and their baseline comorbidities. While TRT may increase serum prostate-specific antigen levels in some men, it often remains within clinically acceptable ranges, and has not been shown to increase the risk of prostate cancer. Current literature supports that TRT does not substantially worsen lower urinary tract symptoms, and may actually improve symptoms in some men. Limited evidence suggests that TRT may initially worsen obstructive sleep apnea in some men, but that this is not a longstanding effect. TRT may result in erythrocytosis in some men, however long-term studies have not reported significant adverse events (e.g. cerebrovascular accident, vascular occlusive events, venous thromboembolisms). Future research will require dedicated focus on evaluation of large, multiethnic cohorts of men through prospective trials to better elucidate both risk and hazard ratios of TRT as it relates to cardiovascular disease, prostate cancer, lower urinary tract symptoms, obstructive sleep apnea, erythrocytosis, and other to-be-determined theoretical risks in men both with and without cardiovascular risk equivalents.

An elderly patient with fluoroquinolone-associated achilles tendinitis.

BACKGROUND Due to their broad-spectrum activity and oral bioavailability, fluoroquinolone antibiotics are commonly prescribed to adults aged >60 years for many common community-acquired infections. The association between fluoroquinolone use and Achilles tendinitis is well established but sometimes missed in clinical practice. Older patients and patients with renal dysfunction are at particularly increased risk for this complication. CASE SUMMARY We present a case of Achilles tendinitis in a 77-year-old patient with renal dysfunction and a urinary tract infection (UTI) treated with ciprofloxacin 250 mg PO QD. Tendinitis developed within several days of the start of treatment and improved within 2 days of treatment cessation, without the need for intervention. The likelihood of ciprofloxacin having caused this reaction was probable (Naranjo score, 7). Early diagnosis and treatment cessation might have prevented tendon rupture, and the tendinitis resolved completely with subsequent physical therapy. CONCLUSION Based on this outcome in this patient with UTI, fluoroquinolones should be used with caution, particularly in patients with risk factors predisposing to tendinitis, including advanced age and renal dysfunction.

“I Don’t Take Creatinine”

With the incorporation of the Affordable Care Act, many of us are seeing dozens of new patients entering our practices. Last week, I saw a young and very muscular man for a health maintenance exam, which was his first doctor’s visit in over 8 years, because he said that he “had always been healthy.” I immediately noticed that his blood pressure was 161/96 and obtained a routine panel of blood tests that revealed a serum creatinine of 1.9 mg/dL and an estimated glomerular filtration rate of 49 mL/min. I asked my nurses to arrange for a follow-up visit to recheck his blood pressure and discuss the results of his blood tests; his repeat blood pressure 3 days later was 165/90. It was a pleasure for me to have this patient establish care with my practice since, if he hadn’t found a doctor, he would have continued to have undiagnosed and untreated hypertension and stage 3 chronic kidney disease (CKD). In further evaluation, I also discovered that he has prediabetes, hyperlipidemia, and nephrotic-range proteinuria. During the follow-up visit, I took the opportunity to explain to the patient some basic pathophysiology of the kidney as well as the significance of his lab results. After a few minutes of what I thought was relatively simple analogies to explain complex medical terms he replied, “I don’t take creatinine; I’m naturally strong, so there must be a mistake.” A recent study published in the New England Journal of Medicine determined that acute kidney injury (AKI) and CKD are likely to be interconnected, suggesting that patients who develop one condition are likely to develop the other at some point, augmenting the need for clinicians to be hypervigilant in their patients, especially those with chronic diseases including diabetes mellitus. This issue of Primary Care: Clinics in Office Practice provides detailed summaries of the current literature on subtopics germane to the principles and practices of nephrology. The articles are dedicated to common renal conditions, including proteinuria, hematuria, renal cysts, AKI, and CKD. A review of the relationship between obesity and the development of kidney disease provides insight into a potentially controllable relationship. As we continue to encounter greater numbers of patients with CKD, the need for primary care clinicians

Diagnosis and office-based treatment of urinary incontinence in adults. Part two: treatment.

Urinary incontinence is a common problem in both men and women. In this review article we address treatment of the various forms of incontinence with conservative treatments, medical therapy, devices and surgery. The US Preventive Services Task Force, The Cochrane Database of Systematic Reviews, and PubMed were reviewed for articles focusing on urinary incontinence. Conservative therapy with education, fluid and food management, weight loss, timed voiding and pelvic floor physical therapy are all simple office-based treatments for incontinence. Medical therapy for incontinence currently is only available for urgency incontinence in the form of anticholinergic medication. Condom catheters, penile clamps, urethral inserts and pessaries can be helpful in specific situations. Surgical therapies vary depending on the type of incontinence, but are typically offered if conservative measures fail.

Diagnosis and Office Based Treatment of Urinary Incontinence in Adults: Part One Diagnosis and Testing

Urinary incontinence is a common problem in both men and women. This review article addresses its prevalence, risk factors, cost, the various types of incontinence, as well as how to diagnose them. The US Preventive Services Task Force, the Cochrane Database of Systematic Reviews, and PubMed were reviewed for articles focusing on urinary incontinence. Incontinence is a common problem with a high societal cost. It is frequently underreported by patients so it is appropriate for primary-care providers to screen all women and older men during visits. A thorough history and physical examination combined with easy office-based tests can often yield a clear diagnosis and rule out other transient illnesses contributing to the incontinence. Specialist referral is occasionally needed in specific situations before embarking on a treatment plan.