Professional Practice Minutes September 7 th, 2016

Transcription

1 Professional Practice Minutes September 7 th, Lung Cancer Screening : Fast Facts Number 1 killer of both men and women in the US (The Global Burden of Cancer 2013) More people die from lung cancer annually than breast, colon, and prostate combined (Rita Edwards) Every 5 mins a women learns she has lung cancer World wide, lung cancer has 1.8 million patients and has caused 1.6 million deaths 75% patients with lung cancer have advanced local or metastatic disease, not amenable to cure (Chest 2006) Survival rate is 16% (CA Cancer J Clin. 2011) In 2012, lung cancer deaths accounted for 27% of all cancer-related deaths in the US In 2016, the American Cancer Society predicts that there will be approximately new cases diagnosed and approximately 158,000 lung cancer associated deaths in US In the US, it has been estimated that 8.6 million people met criteria to be screened and could avert 12,000 deaths of lung cancer annually Lung cancer deaths have begun to decline in men and women due to the decrease in smoking A. Risk Factors: i. Smoking 1. The most important factor in preventing lung cancer is to STOP SMOKING a. Please refer to our awesome Tobacco Dependence program! 2. 85% of lung cancers due to smoking (Rita Edwards) 3. Large population at risk due to cigarette smoking and second hand smoke exposure 4. Approximately 60 million current smokers million former smokers 6. Tobacco is responsible for 1 in 5 deaths and the leading cause of preventable death and illnesses 7. Secondhand Smoke a. More than 126 million are exposed to SHS b. 3,400 lung cancer deaths/ year c. 46,000 heart disease deaths/ year d. Declining: 84% in , 46% in e. 74% of population covered by smoke free policies in work places and restaurants/bars ii. Radiation therapy iii. Other environmental toxins (radon, asbestos, metals) iv. Pulmonary fibrosis v. HIV infection vi. Genetic factors vii. Alcohol viii. Dietary factors B. National Lung Screening Trial Information: On August 4 th, 2011 the New England Journal reported on the study that compared chest x-rays to low dose CAT scans for screening for lung cancer i. 8 years and 53,454 subjects randomized to annual x 3 LDCT vs. CXR ii. 20% lung cancer mortality reduction with the use of low dose CAT scan screening iii. 6.7% all cause mortality reduction iv. Screen 320 individuals to save 1 from lung cancer death v. What was considered positive in the study is any nodule above 4mm

2 C. US Preventive Task force Current Recommendation released on December 2013 D. Lung Screening Guidelines - See screening guide in consult room i. Group 1: years of age 2. Currently a smoker or has quit within the past 15 years 3. Smoked greater than one pack of cigarettes a day for 30+ years ii. Group Smoked one pack or more per day for 20+ years 3. Has one additional risk factor for lung cancer, not to include second hand smoke a. Family history of lung cancer i. Mother, father, sibling, child b. Personal history of chronic lung disease i. COPD, Chronic Bronchitis, Emphysema, Pulmonary Fibrosis c. Occupational exposure to lung carcinogens i. Arsenic, Asbestos, Beryllium, Cadmium, Soot, Chromium, Diesel fumes, Nickel, Silica, Coal smoke d. Radon exposure (Residential, mining, firefighter, military-active combat e. Personal history of cancer (excluding known metastatic disease) i. Lung cancer, lymphoma, head and neck, esophageal, bladder, cervix, colon, kidney, pancreas, stomach E. Harms of Lung Cancer Screenings 1. False positives: 96% of positive tests will not be cancer 2. Radiation exposure: a low dose cat scan is only 1/3 radiation of chest x-ray 3. Patient distress 4. Over diagnosis: we do not know how many of the diagnosis made would have led to the patient s death F. Shared Decision Making i. Always document if you suggest screening and the patient refuses ii. Patients and providers make decisions together based on the best scientific evidence available and the patients values and preferences iii. Honors provider s knowledge and patients right to be fully informed of all care options and potential harms and benefits iv. Gives patients support to make the best individualized care decisions 2. Hepatitis C Screening A. Pennsylvania s Hepatitis C Screening Act i. Signed in to law by PA Governor Tom Wolf on July 20, If goes into effect September 18, ii. Primary care settings like CVIM must screen all people born between 1945 and 1965 for hepatitis C iii. Individuals must be offered the test. We must document offering the test, regardless of if the patient decides to accept testing. iv. If the testing is reactive, we must offer follow up care or refer the patient to appropriate follow up care, including a hepatitis C diagnostic test. B. CVIM Hepatitis C Screening Policy i. All new patients when filling out the Medical Health History form will now be asked two additional questions 1. Would you like to be tested for hepatitis C (suggested if born ) 2. Would you like to discuss issues concerning hepatitis c risk? ii. The HIV Testers will now be involved in asking patients born between if they would like to be tested for hepatitis C

3 iii. The hepatitis C testing can be done for free through our relationships with Chester County Hospital, and only needs to be done one time. iv. If they are found to have active hepatitis c we can refer them to outside gastroenterology for treatment, medications are available through PAP program. Review of Psychiatric Medications at CVIM: Side Effects and Monitoring Parameters Presented by: Stephanie Dangelantonio, Song Oh, Philip Masaitis, PharmD Candidate 2017 I. Selection of treatment consist of many factors (listed below). However, because psychiatric medications have comparable efficacy, both within classes and between classes we base our choice primarily on the safety, tolerability, and side-effects. a. Patient preference b. Prior response c. Family history d. Side-effect profile e. Comorbidities f. Drug interactions g. Half-life h. Cost II. Selective Serotonin Reuptake Inhibitors (SSRI) i. Insomnia, headache, drowsiness, anxiety, nervousness, yawning, decreased libido, nausea, diarrhea, anorexia, dry mouth, weight gain, menstrual changes i. SSRI selectively blocks reabsorption of serotonin into presynaptic neuron, resulting in increased serotonin level at synapse III. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) i. Hypertension, sexual dysfunction, nausea, vomiting, headache, insomnia i. Inhibition of serotonin and norepinephrine reuptake IV. Tricyclic Antidepressants (TCA) i. Anticholinergic symptoms, drowsiness, weight gain, orthostatic hypotension, conduction abnormalities, sexual dysfunction, dry mouth i. TCA inhibits the reuptake of serotonin and norepinephrine V. Lithium i. Fine hand tremor, initial GI complaints (N/V), pruritic acne, alopecia, chronic folliculitis, polydipsia, polyuria, leukocytosis, edema, excessive weight gain, reversible ECG changes, hypothyroidism, diabetes insipidus, arthritis i. Precise mechanism is unknown. Possible mechanism of action is thought to be alteration of sodium transport in nerve and muscle cells resulting intra-neuronal metabolism of catecholamine c. Toxicity i. Lithium level > 1.5 meq/l (Life-threatening if > 2 meq/l) ii. Acute symptoms: 1. Coarse tremor, nausea, diarrhea, blurred vision, vertigo, confusion

4 VI. iii. Severe neurological complications: 1. Seizures, coma, cardiac dysrhythmia, permanent neurological impairment iv. Treatments: 1. Discontinue lithium 2. Supportive care 3. Consider hemodialysis if level > 4 meq/l Atypical Antipsychotics i. Akathisia, increased triglycerides, weight gain, headache, extrapyramidal symptoms, fatigue, restlessness, tremor, increased appetite i. Atypical antipsychotics are agonists of dopamine and serotonin receptors VII. Conclusion a. Primary care physicians and psychiatrists should work closely to examine patient as a whole and provide optimal and individualized patient care b. Proper baseline parameters allow clinicians to rule out non-psychiatric etiologies for patients symptoms c. Standardizing monitoring parameters for psychiatric medications help minimize adverse events and allow clinicians to make proper adjustments to therapy d. Pregnancy test should be done for all female patients in child-bearing age and clinicians must discuss options for contraceptive options prior to initiating psychiatric medications

5 Atypical Antipsychotics Monitoring Parameters for Psychiatric Medications Parameters Baseline Every visit Every 3 month Annually Waist circumference Fasting blood glucose Thyroid function test Hemoglobin A1c Fasting lipid panel Resolution of symptoms Pregnancy test Evaluate/Discuss SSRIs and SNRIs Parameters Baseline Every visit Every 6 month Annually Thyroid function test CBC Electrolytes Resolution of symptoms Pregnancy test Evaluate/Discuss TCAs Parameters Baseline Every visit Every 6 month Annually Thyroid function test CBC Liver function test Resolution of symptoms Pregnancy test Evaluate/Discuss Dental evaluation ECG* *If cardiac risk factors, over the age of 35, concomitant drug use which prolongs QT interval Lithium Parameters Baseline Every visit Every 6 month Annually Thyroid function test CBC Serum creatinine BUN Resolution of symptoms Pregnancy test Evaluate/Discuss ECG* Lithium level ( meq/l) Check trough level (12 hours after last dose) after 10 days, then Q3-6 months in stable patients *If cardiac risk factors, over the age of 35 Prepared by: Song Oh, Stephanie Dangelantonio, Philip Masaitis, PharmD Candidates 2017

6 List of Available Psychiatric Medications at CVIM Class Selective Serotonin Reuptake Inhibitors (SSRI) Drugs Fluoxetine (Prozac) Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) Sertraline (Zoloft) Fluvoxamine (Luvox CR) Serotonin/Norepinephrine Reuptake Inhibitor (SNRI) Alpha-2 antagonist Tricyclic antidepressant (TCA) Dopamine/Norepinephrine-reuptake inhibitor Duloxetine (Cymbalta) Venlafaxine (Effexor XR) Desvenlafaxine (Pristiq) Mirtazapine (Remeron) Amitriptyline (Elavil) Nortriptyline (Pamelor) Doxepin (Silenor) Bupropion (Wellbutrin, Zyban) Serotonin Reuptake Inhibitor/Antagonist Trazodone (Oleptro) Haloperidol (Haldol) Antipsychotics SSRI/5-HT1A receptor partial agonist SSRI/5-HT1A receptor partial agonist/5-ht3 receptor antagonist Anticholinergic Antimanic agent Antianxiety agent Combination therapy Aripiprazole (Abilify) Brexpiprazole (Rexulti) Lurasidone (Latuda) Risperidone (Risperdal) Quetiapine (Seroquel) Olanzapine (Zyprexa) Vilazodone (Viibryd) Vortioxetine (Trintellix) Benztropine (Cogentin) Lithium (Lithobid) Buspirone (Buspar) Olanzapine/Fluoxetine (Symbyax)

7 Antipsychotic Monitoring Flow Sheet Date Weight Waist Circumference Blood Pressure Heart rate TSH T4 Fasting Blood Glucose Hemoglobin A1c Total cholesterol HDL-C LDL-C Triglycerides Parameters Baseline Every visit Every 3 month Annually Waist circumference Fasting blood glucose Hemoglobin A1c Fasting Lipid Panel Thyroid Function Test Resolution of Symptoms Pregnancy test Discuss/Evaluate

8 Side Effect Profile of Psychiatric Medications Antidepressants Medication Insomnia & Anticholinergic Nausea or Sexual Sedation Hypotension agitation effects GI effects dysfunction Weight gain Selective serotonin reuptake inhibitors (SSRIs) Fluoxetine (Prozac) ++ 0/+ 0/+ 0/ Paroxetine (Paxil) ++ 0/+ 0/ Sertraline (Zoloft) ++ 0/+ 0/+ 0/ Fluvoxamine (Luvox) /+ 0/ Citalopram (Celexa) ++ 0/+ 0/+ 0/ Escitalopram (Lexapro) ++ 0/+ 0/+ 0/ Serotonin and norepinephrine reuptake inhibitors (SNRIs) Venlafaxine (Effexor) ++ 0/+ 0/+ 0/ /+ Desvenlafaxine (Pristiq) ++ 0/+ 0/+ 0/ /+ Duloxetine (Cymbalta) 0/+ + 0/ /+ 0/+ Tricyclic antidepressants (TCAs) Amitriptyline (Elavil) 0/ / Nortriptyline (Pamelor) /+ + + Atypical Antipsychotics Medication Sedation EPS Anticholinergic Orthostasis Weight gain Glucose Lipid QTc dysregulation abnormality prolongation Aripiprazole (Abilify) + +/- +/ /- +/- +/- Brexpiprazole (Rexulti) + + +/ /- +/- + Lurasidone (Latuda) /- +/- + Risperidone (Risperdal) /- Quetiapine (Seroquel) Olanzapine (Zyprexa) Key: 0 = absent, +/- = negligible, + = mild, ++ = moderate, +++ = severe List is not all inclusive References: 1. Mann JJ. The medical management of depression. N Engl J Med Oct 27;353(17): Crismon, M. Lynn, et al. "Chapter 50. Schizophrenia." Pharmacotherapy: A Pathophysiologic Approach, 9e. Eds. Joseph T. DiPiro, et al. New York, NY: McGraw-Hill, 2014.