Reports

This report is based on medical evidence presented at sanctioned medical congress, from peer reviewed literature or opinion provided by a qualified healthcare practitioner. The consumption of the information contained within this report is intended for qualified Canadian healthcare practitioners only.

MEDICAL FRONTIERS - 61st Annual Refresher Course for Family Physicians

McGill University, Montreal, Quebec / November 28-December 1, 2010

Which Lifestyle Changes Are Effective?

Lifestyle measures can promote overall health, prevent disease and extend life. In patients already taking antihypertensive or lipid-lowering therapy, lifestyle modification may be more effective than increasing medication doses, noted Dr. Steven Grover, Professor of Medicine and Director, McGill Cardiovascular Health Improvement Program. “If you really want to maximize risk factor management for your patients, look at what they’re doing in their lifestyle, as opposed to which medications and at what doses you are treating them with,” he commented.

Patients’ motivation to start and persist with lifestyle modification is generally poor, he acknowledged. Clinical studies indicate many lifestyle measures do not work rapidly, which leads to discouragement; and some are not based on good science, Dr. Grover remarked. The physician’s recommendations can be difficult to follow and the patient may be further confused by the barrage of health and nutrition information in the media. For example, to ensure a healthy diet, a typical patient may be exhorted to restrict fat, salt, sugar and high-glycemic-index foods, and increase consumption of fruits and vegetables and foods containing anti-oxidants and vitamins. “I would argue that if you want to come up with a healthy eating recommendation for your patients, probably encouraging more fruits and vegetables and staying away from processed foods is the [ideal step]...it’s a simple thing to do,” he maintained.

In contrast, “a little bit of exercise and a little bit of weight loss really do make a difference,” Dr. Grover stated. The Diabetes Prevention Program showed that among patients with a family history of diabetes or with prediabetic blood glucose levels, intensive lifestyle intervention leading to weight loss of 5 to 10 lbs resulted in a 60% reduction in diabetes development compared with placebo. Over a further 10-year follow-up, the lifestyle group participants maintained their health advantage over the placebo group. “If you did nothing else but reduce the incidence of diabetes in your practice, you would make a huge difference... There’s nothing that brings up the cardiovascular risk as much as the presence of diabetes, and the complications of diabetes are of major concern,” Dr. Grover noted. In previously sedentary individuals, moderate daily exercise can decrease blood pressure (BP) by about 5-6 mm Hg and LDL-C by about 5%. Some patients experience impressive increases in HDL-C with exercise, especially with a program sustained over at least 18 months. In a recent study evaluating aerobic exercise and resistance training for patients with diabetes, many patients experienced a substantial drop in fasting glucose and hemoglobin (Hb) A1c levels and were able to reduce antidiabetic therapy.

Aggressive Approach to Diabetes

An aggressive approach to diabetes prevention and risk factor reduction in patients with diabetes is crucial, agreed Dr. Tina Kader, Assistant Professor of Medicine and endocrinologist/diabetes educator at the Jewish General Hospital. Currently, nearly 2.5 million Canadians have diabetes and another 6 million are at high risk for developing the disease, she noted. “We have to diagnose people earlier and get them treated,” she stated.

Achieving HbA1c of <7% reduces diabetes-related complications and death substantially, but 1 in 2 patients with type 2 diabetes is not at this ideal target, she emphasized. In addition to glucose optimization, patients with diabetes require intensive vascular and renal risk management. Attention to lifestyle may be sufficient for patients at very low risk (for example, a young patient with no risk factors except a relatively short duration of diabetes). Those at higher cardiovascular risk should typically be treated with an ACE inhibitor or angiotensin receptor blocker (ARB), antiplatelet therapy and lipid-lowering agents to reach LDL-C <2 mmol/L. If the ACE inhibitor or ARB does not control BP, additional antihypertensive agents should be prescribed to reach the target of <130/80 mm Hg and protect the target organs. This multifactorial management can make a significant impact on cardiovascular events, which are the main threat to patients with diabetes, Dr. Kader indicated.

In the recent STENO-2 trial, patients who underwent intensive treatment of glucose, lipids and BP decreased their risk of myocardial infarction (and/or intervention such as coronary bypass or angioplasty), stroke, surgery for peripheral arterial disease or amputation by 53% compared with patients managed conventionally. The risk reduction has continued over at least 13 years of follow-up, Dr. Kader stressed.

Highlights from Hypertension Guidelines

Most patients with hypertension—and especially those with diabetes—require several medications to achieve their BP goal. The latest Canadian Hypertension Education Program guidelines indicate that low-dose combination regimens are often more effective and well tolerated than stepped care (maximizing doses before adding another medication). In the recent STITCH trial, the initial combination regimen (ACE inhibitor or ARB plus diuretic in a fixed-dose pill) allowed 85% of patients to achieve their target of <140/90 mm Hg. The average initial BP reduction was more than 20 mm Hg, “which was massive,” commented Dr. Luc Trudeau, Assistant Professor of Medicine, Division of Internal Medicine, and cofounder of the Cardiovascular Prevention Centre, Jewish General Hospital. Another combination therapy trial, ACCOMPLISH, showed that patients at high cardiovascular risk experienced 20% fewer events with an ACE inhibitor/dihydropyridine calcium channel blocker regimen combined than with ACE inhibitor plus diuretic. “Diabetics or coronary patients with hypertension should ideally receive this combination,” he indicated.

Sodium restriction is an important lifestyle measure, for both hypertensive and normotensive individuals, asserted Dr. Trudeau. Sodium has acute and chronic effects on the kidneys (fluid retention, lower sodium excretion) and vasculature (increased endothelial dysfunction and reduced vasodilation). Epidemiological studies show that with sodium consumption of more than 6 g/day, cardiovascular disease and overall mortality are increased. On the other hand, restricting sodium intake to new recommended levels will likely have a significant positive effect on BP and cardiovascular events. “If people ate 1800 mg/day less, there would be 1 million fewer hypertensive individuals in Canada,” Dr. Trudeau stated.

Accurate BP measurement is crucial. The newer oscillometric devices have certain advantages over older manometers, Dr. Trudeau remarked. Most notably, because these devices measure BP several times over 5 minutes in a patient who is sitting quietly and alone, they tend to produce a more accurate reading without a “white-coat” effect. “The average with [automated measurement] in your office is the closest you can get to ambulatory monitoring, which is the gold standard,” he emphasized.

Immunizations: Up to Date?

Immunization is as important a disease-preventive step in adults and teens as it is in young children, indicated Dr. John Yaremko, Assistant Professor of Pediatrics, Montreal Children’s hospital. “It’s important that we take the time to [offer appropriate] vaccinations (Table 1) to teenagers and adults because of the consequences of the diseases. The safety profile of the vaccines is [excellent],” he commented.

Outbreaks of measles and mumps have occurred in Canada over the last few years; the majority of cases were in individuals who were inadequately immunized. There is a high rate of measles immunity in patients aged over 40, who were likely infected with wild-type virus, and in children given 2 doses of measles/mumps/rubella (MMR) vaccine. Some patients aged between 13 and 30 may have received only 1 dose, and may be candidates for boosting. Patients who travel to Europe or the Caribbean may also benefit from renewed immunization.

Pertussis incidence in patients aged over 15 years tripled to more than 31% in the years between 1995 and 2004. While pertussis may cause a long-lasting and severe cough (not necessarily with the classic “whoop”) and lead to school or work absence in teens and adults, younger children and infants remain at the greatest risk for morbidity and mortality. Most adults, especially those in contact with youngsters, should probably be immunized or receive a booster.

Invasive meningococcal disease affects about 4 Canadians each week, Dr. Yaremko noted. The meningococcal quadrivalent or C conjugate vaccine should be offered to adolescents or older students, especially those heading off to group living situations such as university residences, even if they were vaccinated earlier in life.

Human papillomavirus (HPV) immunization is recommended for girls and women aged 9 to 26; efficacy is greatest if the vaccine is given before first sexual intercourse. New information suggests women aged up to 45 may also benefit, given that the risk of infection may persist at least up to this age. As of this year, the HPV vaccine is also indicated for boys and men aged 9 through 26, although there is no official recommendation to offer it to males.

Adults over 50 to 60 years of age should be offered immunization against herpes zoster, as the vaccine cuts the incidence of shingles and postherpetic neuralgia by at least 50%.

Table 1. Vaccines to Consider for Teens/Adults Pertussis MMR Meningococcus (quadrivalent or C conjugate) HPV Herpes zoster (age 50 and up)

Efficient Management of Low Back Pain

An algorithm and assessment tool from the McGill Scoliosis and Spine Group (www.mcgill.ca/spineprogram/algorithms/) can aid the efficient assessment of any patient with low back pain. The algorithm starts in the waiting room, where patients should be asked to complete an Oswestry score questionnaire and the STartT Back screening tool. (These questionnaires, which help qualify pain and disability, should also be completed at every follow-up visit.) The history and physical examination will reveal symptoms or signs that suggest serious illness requiring emergency care or a specific diagnosis such as myelopathy or spinal stenosis. For most patients with nonspecific pain, education (for example, about the benefits of continued activity vs. bed rest) and a short course of analgesic medication with or without muscle relaxants will be sufficient, observed Dr. Jean Ouellet, Surgeon and Chief of the Scoliosis and Spine Service at the Montreal General Hospital. The patient should be re-evaluated after 4 to 6 weeks if the pain has not subsided. At this point, the physician may consider imaging or investigations. In addition, they should consider whether “yellow flags” —psychological or social issues—are contributing to chronic pain or disability, noted Dr. Mohan Radhakrishna, Head of Physical Medicine and Rehabilitation at McGill. Patients who remain symptomatic for weeks to months after an initial visit for back pain may require referral to a multidisciplinary spine or pain program.

Physiotherapy is another treatment option for low back pain, although there is sparse evidence about the benefits of specific interventions for a given pain type or syndrome, acknowledged Richard Preuss, Assistant Professor, McGill School of Physical and Occupational Therapy. However, programs involving muscle extension, core stabilization and/or spinal manipulation appear to achieve the best results. Patients who experience pain centralization (the receding of pain toward the midline) with extension or range of motion exercise appear to have a good prognosis with this treatment modality. If the patient’s condition has not improved after 6 to 10 sessions, physiotherapy probably should be discontinued.

Opioids: Guidelines Counsel Caution

Patients with severe or chronic pain may eventually require opioid analgesics for relief. Canadian guidelines released this year (www.nationalpaincentre.mcmaster.ca) are extremely helpful for physicians wishing to initiate and monitor opioid use, explained Dr. Mary-Ann Fitzcharles, Associate Professor and Rheumatologist, Montreal General Hospital. Physicians should be aware of the pain types for which opioids are (e.g. nociceptive or neuropathic pain) or are not effective (e.g. headache, irritable bowel syndrome, repetitive strain injury); and that response to individual opioid agents differs widely. Opioids should be given only to patients about whom the physician has comprehensive knowledge, including the medical indication for pain control and risk factors such as previous history of drug or alcohol abuse or diversion, depression or anxiety or other red flags. All this information should be documented, she advised; a risk questionnaire available in the guidelines can be helpful. The trial dose is usually 200 mg morphine or equivalent; there should be no dose increase for at least a week. The use of controlled-release, long-acting medications is generally preferred. The patient should not expect a complete resolution of pain; a drop of 2 to 3 points on a pain scale is considered a reasonable response. Reassessment should take into account efficacy, functioning and side effects, especially those related to cognition and driving ability. Monitoring for abuse should be ongoing, as “[it] is more common than we think,” she cautioned. “Be sure if you are prescribing an opioid that it is being used for pain.”

Vitamin D Supplementation Often Required

Vitamin D has received a great deal of attention not only because of its implications for bone health but the possibility it may affect the risk of developing numerous other diseases, from influenza to cancer and multiple sclerosis. Adequate vitamin D assists in the prevention of osteoporosis and fractures. In elderly individuals, it also improves muscle strength and lower extremity function, thereby reducing the risk of falls. Vitamin D also plays a role in regulation of cell proliferation, differentiation, apoptosis and angiogenesis in numerous nonskeletal tissues, noted Dr. Suzanne Morin, an associate professor and Director, Internal Medicine Outpatient Department, Montreal General Hospital.

A recent Canadian study suggested that only about a third of Canadians have levels of 25-hydroxy-vitamin D of >75 nmol/L, the level sufficient to increase or maintain bone mineral density and quality and prevent fractures. Most patients will require oral supplementation to attain this level, especially in the winter, Dr. Morin remarked. “We still have a long way to go in terms of educating patients about the importance of vitamin D supplementation.” (New age-related recommendations for vitamin D intake are shown in Table 2). Recommended calcium intake is now 1200 mg/day, due to evidence that higher intake may increase the risk of kidney stones and cardiovascular events. Ideally, calcium should come from dietary sources.

Summary

Primary care physicians have an important role in the prevention of diseases that impair survival and quality of life. Attention to lifestyle, especially exercise and nutrition, can assist in the prevention of numerous illnesses. Other preventive steps include monitoring of immunization status and vitamin D levels. Hypertension and back pain are common reasons for office visits. Guidelines and algorithms are available to help in efficient management of these conditions, as well as for the initiation of opioid analgesics for severe pain.