Primary Issues iPad Giveaway Announcement

Our winner for the Winter 2011 drawing is Ms. Corazon Llamas of Washington. Congratulations, Ms. Llamas!

“Thank you so much. I’m looking forward to getting the iPad and use it to access your website for more CME where ever I may be.” C. Llamas, BSN, RN

Thank you, Ms. Llamas, we are thrilled to give you that opportunity!

Stay tuned for another promotion beginning later this year. Another opportunity you won’t want to miss.

Copyright 2012 Primary Care Education, Inc. All Rights Reserved.

Acute Sinusitis—Antibiotics, or Watch and Wait?

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A recent article in JAMA suggests that among 133 adults with uncomplicated rhinosinusitis, treatment with amoxicillin resulted in no significant difference in symptoms compared with placebo. “There is now a considerable body of evidence from clinical trials conducted in the primary care setting that antibiotics provide little if any benefit for patients with clinically diagnosed acute rhinosinusitis. Yet, antibiotic treatment for upper respiratory tract infections is often both expected by patients and prescribed by physicians,” the researchers write.

Take a minute to read the abstract. How do you currently treat acute sinusitis in adults?  Will this study change your treatment patterns? 

AHA: Women at Equal Risk for PAD

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According to a new scientific statement published by the American Heart Association (AHA),[1] women with peripheral artery disease (PAD) are two to three times more likely to have a stroke or heart attack than women without PAD—yet the condition remains often unrecognized and untreated. AHA is recommending that healthcare providers proactively increase awareness of and test women at risk for PAD. The statement also calls for more women-focused research into the disease.

PAD is a serious circulatory disease caused by a buildup of fat and other materials in blood vessels outside of the heart, usually in the legs, feet, and arms. Left untreated, it can increase heart attack and stroke risk, severely limit walking ability, and cause tissue death requiring limb amputation. About 8 million people in the United States have PAD and most available research suggests a nearly equal prevalence among men and women.

Only about 10% of those with PAD experience the warning sign of leg pain typically associated with it, and this pain usually goes away while resting. Many people experience no symptoms at all. As a result, few sufferers receive prompt treatment although PAD care leads to more than 1.1 million medical office visits annually, according to the new statement.

The rate of deaths and the healthcare costs associated with PAD are at least comparable with those of heart disease and stroke. While women suffer an immense burden from PAD, current data demonstrate that most women still remain unaware of their risk.

Unfortunately, there are too few women enrolled in clinical trials to provide a clear understanding of how the disease progresses, or to determine with accuracy the incidence and prevalence of peripheral artery disease in women, the statement authors said. The authors of the study recommend conducting more research studies of PAD specifically among women and pooling results from previous studies to obtain an adequate sample size of females.

Published February 21, 2012

Reference

1. Hirsch AT, Allison MA, Gomes AS, et al. A call to action: women and peripheral artery disease: a scientific statement from the American Heart Association [published online ahead of print February 15, 2012]. Circulation. DOI: 10.1161/CIR.0b013e31824c39ba.

Curbing the Rise in U.S. Medical Expenditures

Healthcare costs in the United States have skyrocketed over the past 30 years—from $253 billion in 1980 to more than $2.6 trillion a year in 2010.[1] And the average employee has seen his health insurance premiums increased by 11.3% over the past 10 years.[2]

What’s behind these astronomical cost increases? Is it the cost of pharmaceuticals? Increases in the cost of equipment and hospital personnel? Well, according to a study just published in the Annals of Internal Medicine[3], a good chunk of the increased cost of healthcare over the past decade can be attributed to the overuse of some common screening and diagnostic tests.

The study reports the findings from a committee of internists convened by the American College of Physicians (ACP). The committee represented various specialties, practice environments, and geographic locations throughout the United States. Each member of the group was charged with identifying common medical tests that are unlikely to bring high value to the patient or treating the patient’s condition. A test or intervention was considered valuable if its health benefits could justify potential harms and costs, based on the principle that diagnostic tests should not be performed if the results will not change clinical management. As well, the committee was asked to consider the downstream costs and potential health risks incurred when tests in an asymptomatic patient result in a false-positive.

The committee identified 37 situations it believed do not represent high-value, cost-conscious care. Among them were

• Coronary angiography in patients with stable angina on medical therapy or who lack high-risk criteria on exercise testing
• Annual cholesterol screening for those who have normal levels and aren’t taking cholesterol-lowering drugs like statins
• Magnetic resonance imaging rather than mammography in women at low-to-average breast cancer risk
• Obtaining an electrocardiogram (EKG) to screen for heart disease in those who aren’t at high risk
• Exercise testing for patients with a low risk of heart disease and no chest pain while exercising
• Dual-energy x-ray absorptiometry screening for osteoporosis in women younger than 65 years without risk
• Repeat colonoscopy within 5 years in patients who have no signs of polyps
• Cervical cancer screening in low-risk women aged 65 or older and in women who have had a total hysterectomy for benign disease
• Blood tests for suspected early Lyme disease in those with vague symptoms
• Screening for colorectal cancer or prostate cancer in patients older than age 75 years
• Performing imaging studies, such as MRIs, in patients with nonspecific low back pain
• Ordering extensive blood panels in healthy patients undergoing elective surgery
• Brain imaging scans to evaluate recurrent classic migraines in a patient with a normal neurological exam

Data suggest that there is an abundance of unnecessary testing with some sources estimating that nearly 5%—or almost $700 billion—of the nation’s gross national product is spent on unnecessary tests and procedures that don’t improve patient outcomes.[4] As a physician, you have an ethical and professional responsibility to try and ensure that healthcare resources are spent wisely and responsibly. An accompanying editorial provided some questions you can ask yourself before you order a test (Table 1).[5]

Undoubtedly, many of you will take issue with some of the testing scenarios presented above. The journal invites you to complete a brief Internet survey to indicate how you feel about each of the measures or to add tests to the list.

Jill Shuman, MS, ELS
Published February 21, 2012

References

1. Centers for Medicare & Medicaid Services. National Health Care Expenditures Data, 2010. http://www.cms.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage. Updated January 11, 2012. Accessed February 6, 2012.
2. The Kaiser Family Foundation -and- Health Research & Educational Trust. Employer Health Benefits: 2011 Summary of Findings. http://ehbs.kff.org/pdf/8226.pdf. Accessed February 6, 2012.
3. Qaseem A, Alguire P, Dallas P, et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012;156(2):147-149.
4. Orszag PR. Increasing the value of federal spending on healthcare. Congressional Budget Office. July 16, 2008. http://www.cbo.gov/ftpdocs/95xx/doc9563/07-16-HealthReform.pdf. Accesssed February 6, 2012.
5. Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156(2):162-163.

Evaluating the Newer Antidepressants

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Among the constellation of depressive disorders, major depressive disorder (MDD) is the most prevalent, affecting more than 20.7 million people in the United States.[1] Depression is the second leading cause of disability and premature death (next to heart disease) for all ages and the leading cause for individuals aged 15 to 44.[2] The responsibility for providing mental healthcare is falling increasingly to primary care providers. About half of the care for depression and anxiety is delivered in primary care, with primary care the sole form of healthcare used by more than one-third of patients with a mental disorder.[3]

Pharmacotherapy dominates the medical management of depressive disorders and may include first-generation antidepressants (tricyclic antidepressants and monoamine oxidase inhibitors) and the more recently developed second-generation antidepressants (Table 1). In general, the efficacy of first- and second-generation antidepressants is similar; however, first-generation antidepressants often produce multiple side effects that many patients find intolerable, and the risk for harm when taken in overdose or in combination with certain foods or medications is increased.

In 2009, second-generation antidepressants accounted for $9.9 billion in U.S. sales and were the fourth top-selling therapeutic class of prescription drugs.[4] While the action mechanism of most of these agents is poorly understood, they are believed to work—at least in part—through their effects on neurotransmitters such as serotonin, norepinephrine, or dopamine in the central nervous system. However, little data compares the efficacy of one class of the second-generation antidepressants with another or comparing specific antidepressants within a similar class. 

To fill in this evidence gap, the Agency for Healthcare Research and Quality (AHRQ) recently published a revised review of efficacy differences among second-generation antidepressants.[5] The review analyzes evidence from 234 studies that compared the benefits and harms of second-generation antidepressants for various phases of MDD. 

Overall, the review found no substantial differences in efficacy among second-generation antidepressants for the treatment of MDD. While these drugs are similar in efficacy, they cannot be considered identical drugs. There are individual differences among them with respect to onset of action, adverse events, and some measures of health-related quality of life. Specifically, consistent evidence from multiple trials demonstrates that mirtazapine has a faster onset of action than citalopram, fluoxetine, paroxetine, and sertraline, and that bupropion has fewer sexual side effects than escitalopram, fluoxetine, paroxetine, and sertraline.

Some of these differences are small and might be offset by adverse events. For example, a faster onset of mirtazapine must be weighed against possible decreased adherence because of long-term weight gain. Nonetheless, some of these differences may be clinically significant and influence the choice of a medication for specific patients.

Evidence reviewed by ARHQ suggests

• In general, the various second-generation antidepressants have similar rates of effectiveness. In controlled studies, about 37% of patients saw no improvement and 53% had only partial improvement.
• Between 25% and 33% of patients improved with the addition or substitution of a different drug if  the first drug produced no improvement.
• On average, 63% of patients taking second-generation antidepressants experienced at least one side effect. The most common were nausea and vomiting, constipation, diarrhea, dizziness, headache, and sleeplessness.
• Venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), was associated with a higher incidence of nausea and vomiting than selective serotonin reuptake inhibitors (SSRIs). Venlafaxine was also more likely than the SSRIs to be discontinued due to adverse events, but was less likely to be discontinued because of lack of efficacy. 
• Sertraline was more likely to cause diarrhea than bupropion, citalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, or venlafaxine. Mirtazapine led to higher weight gains than fluoxetine, paroxetine, venlafaxine, or trazodone. Trazodone was associated with higher rates of sleepiness than bupropion, fluoxetine, mirtazapine, paroxetine, or venlafaxine.
• Paroxetine and venlafaxine had the highest rates of discontinuation syndrome—a syndrome that can occur following the interruption, dose reduction, or discontinuation of SSRIs or SNRIs. Fluoxetine produced the lowest rates of the syndrome.
• Second-generation antidepressants worked at different rates. Seven studies funded by the manufacturer of mirtazapine suggested that it worked faster than citalopram, fluoxetine, paroxetine, or sertraline.
• Bupropion was less likely to cause sexual dysfunction than fluoxetine, paroxetine, or sertraline. Paroxetine had higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, or sertraline.
• Efficacy among all of the second-generation medications did not differ substantially for treatment of depression in patients with accompanying anxiety.
• Efficacy among all of the medications did not differ between people older than 55 years, or those with type 2 diabetes. 
• No evidence addressed how second-generation antidepressants compare when a patient responds  to one agent and then is required to switch to a different agent (eg, because of changes in health insurance benefits).

Jill Shuman, MS, ELS
Published February 14, 2012

References

1. Centers for Disease Control and Prevention (CDC). Current depression among adults—United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38);1229-1235.
2. Board on Health Care Services and Institute of Medicine. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington, DC: National Academies Press; 2005.
3. Russell L. Mental health care services in primary care tackling the issues in the context of health care reform. Center for American Progress Website. http://www.americanprogress.org/issues/2010/10/mental_health.html. Published October 2010. Accessed February 6, 2012. 
4. IMS Health Reports U.S. prescription sales grew 5.1 percent in 2009, to $300.3 billion. IMS Health Website. http://www.imshealth.com/portal/site/ims/menuitem.d248e29c86589c9c30e81c033208c22a/?vgnextoid=ff0d3c21b4af1310VgnVCM100000ed152ca2RCRD&vgnextfmt=default. Published April 1, 2010. Accessed February 6, 2012.
5. Gartlehner G, Hansen RA, Morgan LC, et al. Comparative Effectiveness of Second Generation Antidepressants in the Pharmacologic Treatment of Adult Depression: An Update of the 2007 Comparative Effectiveness Review. Comparative Effectiveness Review No. 460. Rockville, MD: Agency for Healthcare Research and Quality. December 2011. AHRQ Publication No. 12-EHC012-EF.
6. Gartlehner G, Hansen RA, Morgan LC, et al. Comparative benefits and harms of second-generation antidepressants for treating major depressive disorder. An updated meta-analysis. Ann Intern Med. 2011;155:772-785.

FDA: Proton Pump Inhibitors Linked to C. Difficile-Associated Diarrhea

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The Food and Drug Administration (FDA) has notified healthcare providers that the use of proton pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–associated diarrhea (CDAD). A meta-analysis reported at the 2010 meeting of the American College of Gastroenterology yielded the same finding. The FDA is working with manufacturers to include information about the increased risk of CDAD with use of PPIs in the drug labels.

Proton pump inhibitors (PPIs) are marketed under various brand and generic drug names as prescription and over-the-counter products (Table 1). Prescription PPIs are used to treat conditions such as gastroesophageal reflux disease (GERD), gastric and duodenal ulcers, and inflammation of the esophagus. Over-the-counter PPIs are used to treat frequent heartburn.

All of the PPIs, both prescription and over-the-counter, are considered part of this notification. As well, FDA is reviewing whether the same risk exists for those who use histamine H2 receptor blockers, which are also used to treat conditions such as GERD, gastric and duodenal ulcers, and heartburn (Table 1).

The FDA has reviewed reports from the FDA’s Adverse Event Reporting System and the medical literature for CDAD cases in patients undergoing treatment with PPIs. Many of the adverse event reports involved patients who were elderly, had chronic and/or concomitant underlying medical conditions, or were taking broad spectrum antibiotics that could have predisposed them to developing CDAD. Patients who have one or more of these risk factors may have serious outcomes from CDAD with concomitant PPI use.

The FDA also reviewed a total of 28 observational studies described in 26 publications. Among all the studies, 23 of them showed a higher risk of C. difficile infection or CDAD associated with PPI exposure compared with no PPI exposure. Most of the studies found that the risk of C. difficile infection or CDAD ranged from 1.4 to 2.75 times higher among patients with PPI exposure compared with those without the exposure.

Have patients contact you immediately if they take PPIs and develop diarrhea that does not subside; a diagnosis of CDAD should be considered. They should also be advised to seek immediate care from a healthcare professional if they have symptoms additional CDAD symptoms (watery stool, abdominal pain, fever) while taking PPIs. Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.

Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program.

Published February 14, 2012

Source: FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs). U.S. Food and Drug Administration (FDA) Website. http://www.fda.gov/Drugs/DrugSafety/ucm290510.htm. Published February 8, 2012. Accessed February 8, 2012.

New ACP Guidelines for Treating Type 2 Diabetes

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According to new guidelines published by the American College of Physicians (ACP) in the Annals of Internal Medicine, metformin should be the first drug of choice in oral therapy for people with type 2 diabetes who don’t respond to diet and lifestyle changes. A second agent can be added if metformin monotherapy fails to control hyperglycemia, but there’s insufficient evidence to recommend one secondary agent over another.

The guidelines were derived from a comparative safety and effectiveness analyses of studies published between 1966 and April 2010. The authors evaluated the evidence of the impact of high blood sugar levels on clinical outcomes such as body weight, cholesterol and triglyceride levels, all-cause mortality, cardiovascular disease and death, neuropathy, and kidney function.

Highlights of the new guideline include

• When diet, exercise, and weight loss fail to improve hyperglycemia in patients with diabetes, clinicians should consider adding oral drug therapy.
• Unless contraindicated, metformin is the drug of choice for initial monotherapy. While the evidence shows that most medications reduce HbA1c to a similar degree, metformin appears to be more effective than the others in reducing HbA1c. Metformin is also associated with reduced weight, improved cholesterol profiles, and fewer episodes of hypoglycemia. Metformin, however, may also cause more gastrointestinal side effects than other medications.
• If metformin and lifestyle modifications fail to control hyperglycemia, a second oral agent should be added. There are currently 11 classes of drugs approved for treating hyperglycemia and no combination therapy is recommended over another. However, some studies indicate that metformin plus another agent generally has better efficacy than other monotherapies or combination therapies. While generic sulfonylureas are the cheapest second-line agents, the evidence suggests there is an increased risk of hypoglycemia with combination therapies that include a sulfonylurea. As well, clinicians are warned about the risk of heart failure associated with the thiazolidinedione class, which includes Avandia and Actos. The authors did not address combining more than two agents, and emphasize that patients with persistent hyperglycemia despite oral therapy may eventually need insulin.

The guidelines do not provide recommendations as to the best time to start oral therapy. Instead, clinicians should take into account factors such as life expectancy, risk of microvascular and macrovascular complications, risk for adverse events related to glucose control, and patient preference. While the researchers note than an HbA1c lower than 7% is a reasonable goal for many patients, each patient’s HbA1c target should also be based on an individual risk assessment.

The guideline’s authors also stated there is not enough evidence to draw conclusions about the comparative effectiveness of medications on all-cause and cardiovascular mortality, cardiovascular and cerebrovascular morbidity, and microvascular outcomes.

Published February 9, 2012

Source: Qaseem A, Humphrey LL, Sweet DE, et al. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2012;156(3):218-231.

Sex Is Safe for Many Patients With Heart Disease

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Your patients will be happy to hear the latest advice from the American Heart Association (AHA)!

According to a newly released AHA scientific statement,[1] most men and women with stable cardiovascular disease can safely engage in sexual activity. The statement goes on to say that sexual activity is “reasonable” for patients with coronary artery disease who have no or mild angina and for patients with compensated and/or mild heart failure.

Published online in Circulation: Journal of the American Heart Association, the statement contains comprehensive recommendations by experts from various fields including heart disease, exercise physiology, sexual counseling, and urology.

The guidelines were created in part because many patients are uncomfortable talking about sexual activity with their healthcare providers. For many patients, sexual activity is an important quality-of-life measure and they should not have to live with an uncertainty or fear that prevents them from enjoying sexual relations.

Decreased sexual activity and function—common in men and women with cardiovascular diseases—is often related to anxiety about the level of activity required for lovemaking. However, the absolute rate of cardiovascular events during sexual activity, such as heart attacks or chest pain caused by heart disease, is miniscule because sexual activity is usually for a short time. In fact, the authors state that sexual activity is the cause of less than 1% of all heart attacks. The statement also states that sexual activity with one’s usual partner is roughly equivalent to mild or moderate physical activity at 3 to 5 metabolic equivalents—roughly equal to the amount of energy generated per hour by moderate bike riding, tennis doubles, or moderate weight lifting.[2]

Certain patients, such as those with severe heart disease who have symptoms while at rest, should put off sex until their condition has stabilized. But if patients can walk briskly or climb two flights of stairs without experiencing chest pain, abnormal heart rhythms, or shortness of breath, they’re almost certainly ready to start having sex again, the guidelines say.

The one caveat? Married men having affairs—often with younger women in unfamiliar settings that include excessive food and alcohol—may be at higher risk. These circumstances can add to stress that may increase the risks, evidence from a handful of studies suggests.

The recommendations include

• After a diagnosis of cardiovascular disease, it is reasonable for patients to be evaluated by their physician or healthcare provider before resuming sexual activity.
• Cardiac rehabilitation and regular physical activity can reduce the risk of cardiovascular complications related to sexual activity in people who have had heart failure or a heart attack.
• Women with cardiovascular disease should be counseled on the safety and advisability of contraceptive methods and pregnancy based on their patient profile.
• Patients with severe heart disease who have symptoms with minimal activity or while at rest should not be sexually active until their cardiovascular disease symptoms are stabilized with appropriate treatment.
• Patients should be assessed to see if their sexual dysfunction is related to underlying vascular or cardiac disease, anxiety, depression, or other factors.
• Drugs that can improve cardiovascular symptoms or survival should not be withheld due to concerns that such drugs may impact sexual function.
• Drugs to treat erectile dysfunction are generally safe for men who have stable cardiovascular disease. These drugs should not be used in patients receiving nitrate therapy for chest pains due to coronary artery disease (blockages in the arteries that supply the heart with blood), and nitrates should not be administered to patients within 24 to 48 hours of using an erectile dysfunction drug (depending on the drug used).
• It is reasonable for postmenopausal women with cardiovascular disease to use estrogen that’s topically or vaginally inserted for the treatment of painful intercourse.
  The scientific statement has been endorsed by several other medical societies, including the American Urological Association, American Association of Cardiovascular and Pulmonary Rehabilitation, International Society of Sexual Medicine, and the American College of Cardiology Foundation.
   

Jill Shuman, MS, ELS
Published January 31, 2012

References

1. Levine GN, Steinke EE, Bakaeen FG, et al. Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association [published online ahead of print January 19, 2012]. Circulation. doi:10.1161/CIR.0b013e3182447787.
2. Centers for Disease Control and Prevention (CDC). General physical activities defined by level of intensity. Available at: http://www.cdc.gov/nccdphp/dnpa/physical/pdf/PA_Intensity_table_2_1.pdf. Accessed January20, 2012.

Meaningful Use: The Measures Defined by Information That Leaves the EMR

Program Overview

The drive toward Meaningful Use and meeting the government mandated measures has ushered in a new sense of urgency for practices and health systems to get the most out of their EHR/EMR software. However, there is a constant need for education to ensure fulfillment of the Meaningful Use Core Measures and compliance with HHS/CMS guidelines. With so much information available at the “30,000 foot” overview level, this presentation is designed to give some specifics on five (5) of the more “controversial” measures.

• Core Measure 12 of 15 – Electronic Copy of Personal Health Record
• Core Measure 13 of 15 – Clinical Summary
• Core Measure 14 of 15 – Electronic Exchange of Information
• Core Measure 15 of 15 – Risk Assessment
• Menu Set Measure 5 of 10 – Patient Portal 

Learning Objectives

After completing this activity, the participant should be better able to

1. Determine which of the five (5) measures, if any, need workflow changes or further documented process within their practices in order to be fully compliant for your Meaningful Use Attestation Period
2. Identify nuances/details of each of the five (5) measures that could potentially cause you to struggle with the measure HIPAA

 Published February 7, 2012

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Does Every Adult Patient Need Aspirin?

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Your patients are likely to ask you about a meta-analysis just published in the Archives of Internal Medicine showing that while aspirin may reduce the risk of heart attack in middle-aged adults without known heart disease, the benefits are only modest.[1] In addition, aspirin appeared to confer no significant protection against stroke or fatal heart attack, and the benefits against a nonfatal heart attack were offset by clinically important bleeding events.

The meta-analysis included nine randomized placebo-controlled trials with a total of 102,621 participants without a prior history of cardiovascular disease (CVD) or stroke. During a mean follow-up of six years, treatment with aspirin reduced total cardiovascular events by 10%, which was driven primarily by a 20% reduction in nonfatal heart attacks. There was no significant reduction in cardiovascular deaths or cancer mortality. However, there was a 70% increased risk of bleeding events, 30% of which were considered “nontrivial.” The number needed to treat to prevent one nonfatal heart attack was 162, compared with a number needed to harm of 73 for causing a nontrivial bleed. In other words, for every two patients that take aspirin to prevent a nonfatal myocardial infarction (MI), two patients will have a significant bleeding episode.

Of note is that this study found no association between aspirin and chemoprevention. This contradicts the findings from a 2011 meta-analysis showing that aspirin has a protective effect against several different kinds of cancer.[2] This may be due to the length of follow-up in the nine studies included in this new meta-analysis not being long enough to detect any major effect on cancer prevention or that this new meta-analysis included far fewer patients who developed cancer than did the earlier meta-analysis.

What can you tell patients?

Low-dose aspirin has become a mainstay of therapy for the prevention of CVD in people with a history of cardiovascular events. However, its role in primary prevention has been less clear. This study strikes a cautionary note in that more people were likely to experience a bleeding episode than to be protected from a cardiovascular event. Therefore, the authors call for careful deliberation between you and your patients to discuss the risk versus the benefit of aspirin use and to encourage patients to make lifestyle changes that focus on reducing blood pressure and smoking cessation.

To date, the data argue against the routine use of aspirin for primary prevention of CVD for individuals at low absolute risk of CVD. As the current guidelines recommend, it is reasonable to consider using aspirin for primary prevention in higher-risk individuals without known CVD if they are deemed to have a greater benefit to risk ratio and after taking into account patient preferences. Or, you might consider exploring every-other-day dosing. And remember that the Centers for Medicare & Medicaid Services has now expanded coverage of CVD prevention to include intensive behavioral counseling in addition to evaluating the individual benefit-risk ratio for aspirin use in primary prevention.

 Published January 31, 2012

References

1. Seshasai SR, Wijesuriya S, Sivarkumaran R, et al. Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials [published online ahead of print January 9, 2012]. Arch Intern Med. doi:10.1001/archinternmed.2011.628.
2. Rothwell PM, Fowkes FG, Belch JF, et al. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trial. Lancet. 2011;377(9759):31-41.