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AFP Journal Review March 1, 2010. Lianne Beck, MD Assistant Professor Emory Family & Preventive Medicine. Articles. Management of COPD Exacerbations Adverse Effects of Antipsychotic Medications Common Tongue Conditions in Primary Care Urine Drug Screening: A Valuable Office Procedure.

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afp journal review march 1 2010

AFP Journal ReviewMarch 1, 2010

Lianne Beck, MD

Assistant Professor

Emory Family & Preventive Medicine

  • Management of COPD Exacerbations
  • Adverse Effects of Antipsychotic Medications
  • Common Tongue Conditions in Primary Care
  • Urine Drug Screening: A Valuable Office Procedure
management of copd exacerbations
Management of COPD Exacerbations
  • Exacerbations occur an average of 1.3 times per year.
  • In US, exacerbations have contributed to a

102 % increase in COPD-related mortality from 1970 to 2002 (21.4 to 43.3 deaths per 100,000 persons).

definition and classification
Definition and Classification
  • Global Initiative for Chronic Obstructive Lung Disease (GOLD)
  • ATS and ERS define an exacerbation as an acute change in a patient's baseline dyspnea, cough, or sputum that is beyond normal variability, and that is sufficient to warrant a change in therapy.

The Diagnosis of COPD







Prolonged expiration





Reduced BS

indoor/outdoor pollution



gold guidelines classifications

FEV1 / FVC < 70%

50% < FEV1< 80%

FEV1 / FVC <70%

30%< FEV1 <50%

GOLD Guidelines: Classifications






Education, avoidance

of risk factors,

Pneumovax/flu vaccine

At RiskStage 0

+/- Chronic cough,


FEV1 / FVC <70%

MildStage I

+/- Chronic cough,


Add short-acting

bronchodilator p.r.n.

FEV180% predicted

ModerateStage II

+/- Chronic cough, sputum,


Add regular treatment with one or more LABD


SevereStage III

+/- Chronic Cough, sputum,


Add ICS if repeated exacerbations

Very Severe

Stage IV

Chronic respiratory failure or cor pulmonale

FEV1 / FVC <70%


Add long term oxygen

Consider surgical tx

Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: NHLBI/WHO Workshop Report. Bethesda, Md: National Heart, Lung, and Blood Institute, National Institutes of Health;Updated 2003. NIH publication 2701A.

management of copd exacerbations8
Management of COPD Exacerbations
  • Symptoms
    • Cardiac (Chest tightness, Tachycardia)
    • Musculoskeletal (Decreased exercise tolerance)
    • Psychiatric (Confusion, Depression, Insomnia, Sleepiness)
    • Pulmonary (Change in volume, color, or tenacity of sputum, Cough, Dyspnea, Tachypnea, Wheezing)
    • Systemic (Fatigue, Fever, Malaise)
factors that increase risk of severe exacerbations
Factors that Increase Risk of Severe Exacerbations
  • AMS
  • At least 3 exacerbations in the previous 12 months
  • BMI of 20 kg/m2 or less
  • Marked increase in symptoms or change in vital signs
  • Medical comorbidities
  • Poor physical activity levels
  • Poor social support
  • Severe baseline COPD (FEV1/FVC ratio less than 0.70 and FEV1 less than 50 percent of predicted)
  • Underutilization of home oxygen therapy
etiology of exacerbations
Etiology of Exacerbations
  • Pulmonary Infection
  • Air pollution (tobacco smoke, occupational exposures, ozone)
  • CHF
  • Nonpulmonary infections
  • PE
  • Pneumothorax
  • One third of exacerbations have no identifiable cause.
other treatment options lacking efficacy
Other Treatment Options Lacking Efficacy
  • Parenteral methylxanthines (theophylline) not routinely recommended
  • Several therapies lack adequate evidence for routine use in the treatment of COPD exacerbations, including:
    • mucolytics (e.g., acetylcysteine )
    • nitric oxide
    • chest physiotherapy
    • antitussives
    • morphine
    • nedocromil
    • leukotriene modifiers
    • phosphodiesterase IV inhibitors
    • immunomodulators
criteria for discharge
Criteria for Discharge
  • Stable clinical symptoms
  • Stable or improving arterial partial pressure of oxygen of more than 60 mm Hg for at least 12 hours.
  • Should not require albuterol more often than every 4 hours.
  • If the patient is stable and can use a metered dose inhaler, there is no benefit to using nebulized bronchodilators
  • In-home support, such as an oxygen concentrator, nebulizer, and home health nurse services, should be arranged before discharge
improving mortality morbidity
Improving Mortality & Morbidity
  • Smoking cessation
  • Immunization against influenza and pneumonia
  • Pulmonary rehabilitation have been shown to improve function and reduce subsequent COPD exacerbations
  • Long-term oxygen therapy decreases the risk of hospitalization and shortens hospital stays in severely ill patients with COPD
adverse effects of antipsychotic medications
Adverse Effects of Antipsychotic Medications
  • The FGAs block dopamine D2 neuroreceptor.
  • SGAs were launched in 1989 when investigators found that clozapine (Clozaril) was more effective than chlorpromazine, with fewer extrapyramidal symptoms.2
  • These new anti-psychotics were considered atypical because they targeted neuroreceptors other than only dopamine.
  • Over the past two decades, SGAs have dominated prescribing preferences in the United States under the assumption that they are more effective and safer than FGAs.
extrapyramidal symptoms
Extrapyramidal Symptoms
  • Pseudoparkinsonism
    • reversible syndrome that includes tremulousness in the hands and arms, rigidity in the arms and shoulders, bradykinesia, akinesia, hypersalivation, masked facies, and shuffling gait.
  • Akathisia
    • a feeling of inner restlessness that can be manifested as excessive pacing or inability to remain still for any length of time
  • Acute dystonia
    • spastic contractions of the muscles, including oculogyric crisis, retrocollis, torticollis, trismus, opisthotonos, or laryngospasm
  • Tardive dyskinesia (may not be reversible)
    • involuntary movements including myoclonic jerks, tics, chorea, and dystonia. Usually involving orofacial region. Most evident when patients are aroused, but ease during relaxation and disappear during sleep.
  • Asymptomatic
  • Gynecomastia
  • Galactorrhea
  • Oligo- or amenorrhea
  • Sexual dysfunction
  • Acne
  • Hirsutism
  • Infertility
  • Loss of bone mineral density
cautious use in the elderly
Cautious Use in the Elderly
  • In April 2005, the FDA issued a boxed warning for SGAs after a meta-analysis showed a 1.6- to 1.7-fold increase in the risk of death associated with their use in this population.
  • In June 2008, after two large cohort studies showed similar risk with FGAs, boxed warnings were added to this class as well.
  • The cause of this increased mortality is at least in part from sudden cardiac death, as well as cerebrovascular accidents.
  • Currently, there are no medications approved for the treatment of dementia-related psychosis.
  • Before medication is prescribed, behavioral interventions should be attempted. Any use of antipsychotics for dementia-related psychosis should be preceded by a discussion with patients, families, and caregivers about the increased risk of CVA and death.
common tongue conditions in primary care
Common Tongue Conditions in Primary Care
  • Prevalence is 15.5 % in U.S. adults.
  • Increased in those who wear dentures or use tobacco.
  • The most common tongue condition is geographic tongue, followed by fissured tongue and hairy tongue.
  • Thorough history, including onset and duration, antecedent symptoms, and tobacco and alcohol use
  • A complete head and neck examination, with careful assessment for lymphadenopathy, is essential.

Traumatic Appears along the bite line as a Excisional biopsy to r/o

fibroma focal, thickened area that is dome neoplasia

shaped, pink, and smooth

lingual thyroid nodule
Lingual Thyroid Nodule
  • 90 % of ectopic thyroid tissue is associated with the dorsum of the tongue.
  • Smooth nodular mass of tissue located in the midline of the posterior dorsal surface of the tongue.
  • Up to 70 % of patients with a lingual thyroid have hypothyroidism.
  • Some patients have a sensation of a lump or difficulty swallowing.
  • Symptoms are more common during increased metabolic demand, such as in adolescence or pregnancy
  • If hypothyroidism is present, thyroid replacement can decrease the size of the lingual thyroid and improve obstructive symptoms.
  • Surgical excision is often advised for patients with a lingual thyroid and normal thyroid function; however, this may lead to a need for postoperative thyroid replacement because the lingual thyroid is usually the only functioning thyroid tissue in these patients
lymphoepithelial cysts
Lymphoepithelial Cysts
  • Yellowish nodules located on the ventral surface of the tongue, tonsillar region, or floor of the mouth.
  • Benign and thought to arise from the entrapment of salivary epithelium in lymphoid aggregates during embryogenesis.
  • Biopsy is required to confirm the diagnosis.
uds a valuable office procedure
UDS: A Valuable Office Procedure
  • Used to enhance workplace safety, monitor patients' medication compliance, and detect drug abuse
  • Ordering and interpreting UDS requires an understanding of the different testing modalities, the detection times for specific drugs, and the common reasons for false-positive and false-negative test results.
common indications for uds
Common Indications for UDS
  • Workplace mandate
    • pre-employment screenings
    • returning to work after an unexplained absence
    • industrial accidents where damage, injury, or loss of life may have been caused by negligence or impairmen
    • federal regulations
    • random testing for continued licensure or employment
  • Safety-sensitive occupations (trucking, mass transit, rail, airline, marine, or oil and gas pipeline sectors)
  • Military or sports participation
  • Legal or criminal situations (post-accident testing, parole)
  • Health reasons (rehabilitation testing, pain management, treatment compliance monitoring, determining a cause of death)
universal precautions in pain management
Universal Precautions in Pain Management
  • Risk stratification
  • Medication agreement or pain contract
  • Adherence monitoring
  • Urine drug screening
urine drug screening
Urine Drug Screening
  • A negative UDS result does not exclude occasional or even daily drug use.
  • The benefits of frequent drug testing are greatest in patients who engage in moderate drug use.
  • Random screening in patients taking opioids for pain management may reveal abnormal findings
    • absence of the opioid
    • presence of additional nonprescribed substances
    • detection of illicit substances
    • adulterated urine samples
testing methods
Testing Methods
  • Before screening, ask about prescription, over-the-counter, and herbal medication use.
  • 2 main types of urine drug screening:
    • Immunoassay testing
      • uses antibodies, inexpensive, rapid and is preferred initial method
    • Gas or liquid chromatography
      • expensive, time consuming, more accurate, used to confirm
applying test results
Applying Test Results
  • The routine opiate test is designed to detect morphine metabolites, which include heroin and codeine
  • Codeine is broken down to smaller amounts of morphine, thus the screen will be positive for both if the patient takes codeine
  • Hydrocodone is metabolized to hydromorphone in the liver; so, a patient taking hydrocodone as prescribed may test positive for hydromorphone.
  • Codeine, if taken in high quantities, can also be metabolized to small amounts of hydrocodone.
applying test results47
Applying Test Results
  • An expanded opiate panel is needed to detect other commonly used narcotics, including fentanyl (Duragesic), hydrocodone (Hycodan), methadone, oxycodone (Roxicodone, Oxycontin), buprenorphine, and tramadol (Ultram).
  • Except for marijuana, which can be detected for weeks after heavy use, positive results reflect use of the drug within the previous 1-3 days.
  • Casual passive exposure to marijuana smoke is unlikely to give a positive test result.
  • Adherence can be masked by dilute urine, time since ingestion, quantity ingested, or the laboratory's established threshold limits.
  • Discussing adherence with the patient is helpful, but testing for a particular medication may be necessary to resolve issues of diverting the prescribed medication.
preventing and detecting specimen tampering
Preventing and Detecting Specimen Tampering
  • Many ways for patients to circumvent testing
    • Adding adulterants to urine at the time of testing
    • Urine dilution through excessive water ingestion
    • Consumption of substances that interfere with testing
    • Substitution of a clean urine sample
legal issues for drug testing
Legal Issues for Drug Testing
  • Legally mandated drug testing requires the expertise of a Certified Medical Review Officer (CMRO).
  • When performing non–legally mandated tests, physicians should be familiar with the specific drug screening statutes and regulations in their own state.
  • State regulations might address chain of custody requirements, patient privacy, which specimens may be screened, and how results may be used or shared.
  • Reference laboratories routinely offer medical review officer services and telephone consultation with a laboratory toxicologist.
  • When in doubt, the rules and best practices of the U.S. Department of Transportation provide a legally defensible framework for most jurisdictions.

1. A 55-year-old man with a history of stable chronic obstructive pulmonary disease (COPD) has reduced exercise tolerance and increased cough and tenacity of sputum. A COPD exacerbation is suspected. Which one of the following tests should be performed?  (check one)

A. Chest radiography.

B. Pulse oximetry.

C. Arterial blood gas measurement.

D. Brain natriuretic peptide measurement.


2. Although the patient in the previous question does not have severe respiratory distress, referral to the emergency department for evaluation is being considered. Which of the following factors increase the risk of a severe COPD exacerbation?  (check all that apply)

A. Altered mental status.

B. Underutilization of home oxygen therapy.

C. Body mass index greater than 30 kg per m2.

D. At least three exacerbations in the previous 12 months.


3. Which one of the following statements about selection of an antipsychotic medication is correct?  (check one)

A. There is little difference in effectiveness between first-generation antipsychotics (FGAs) and most second-generation antipsychotics (SGAs).

B. Adverse effects are similar and, therefore, are not important to consider.

C. SGAs are consistently more effective than FGAs.

D. Agents with greater potency against dopamine D2 neuroreceptors are generally preferred.


4. Which one of the following statements about cardiac arrhythmia associated with antipsychotic use is correct?  (check one)

A. It is generally mild and transient.

B. Sudden cardiac death is approximately twice as common in patients taking antipsychotics as in the general population.

C. It is more common with high-potency FGAs.

D. It is less common with ziprasidone (Geodon) than with other SGAs.


5. Which of the following statements about adverse effects of antipsychotic medications are correct?  (check all that apply)

A. Patients may become tolerant of sedative effects.

B. Weight gain is dose dependent.

C. Anticholinergic effects are more common with clozapine (Clozaril) than with other SGAs.

D. Tardive dyskinesia is easily and quickly reversible.


6. A patient presents with a smooth, glossy tongue that is associated with pain and burning. Which one of the following is the best strategy to diagnose the likely associated condition?  (check one)

A. Biopsy.

B. Nutritional assessment.

C. Testing for human immunodeficiency virus infection.

D. Close observation.


7. Which one of the following statements about symptomatic geographic tongue is correct?  (check one)

A. Daily debridement with a tongue scraper is recommended.

B. The condition is associated with diabetes.

C. Topical steroid gels and antihistamine mouth rinses can alleviate discomfort.

D. Treatment should be directed at the underlying disorder.


8. Which one of the following approaches is most effective in infants with tongue-tie (ankyloglossia) and breastfeeding problems?  (check one)

A. Advise the mother to stop breastfeeding.

B. Provide education and lactation support alone, because surgery is rarely effective.

C. Consider frenulectomy.

D. Inform the mother that tongue-tie rarely causes feeding problems.


9. Which one of the following is the preferred initial test for urine drug screening? (check one)

A. Immunoassay.

B. Polymerase chain reaction.

C. High-performance liquid chromatography.

D. Rapid, office-based enzyme-linked immunosorbent assay.


10. Which one of the following drugs can cause a false-positive test result when screening for tetrahydrocannabinol (THC)?  (check one)

A. Ibuprofen.

B. Sertraline (Zoloft).

C. Desipramine (Norpramin).

D. Bupropion (Wellbutrin).

E. Dextromethorphan.


11. Which of the following are among the most commonly tested for substances during urine drug screenings?  (check all that apply)

A. Fentanyl (Duragesic).

B. Cocaine.

C. Phencyclidine (PCP).

D. Morphine.

  • Evensen A. Management of COPD Exacerbations. American Family Physician. March 1, 2010.
  • Muench J, Hamer A. Adverse Affects of Antipsychotic Medication. American Family Physician. March 1, 2010.
  • Reamy B, Derby R, Bunt C. Common Tongue Conditions in Primary Care. Am Fam Physician. March 1, 2010.
  • Standridge R, Adams S, Zotos A. Urine Drug Screening: A Valuable Office Procedure. Am Fam Physician. March 1, 2010.