AFP Journal Review March 1, 2010

1. AFP Journal ReviewMarch 1, 2010 Lianne Beck, MD Assistant Professor Emory Family & Preventive Medicine

2. Articles • Management of COPD Exacerbations • Adverse Effects of Antipsychotic Medications • Common Tongue Conditions in Primary Care • Urine Drug Screening: A Valuable Office Procedure

3. 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).

4. Definition and Classification • Global Initiative for Chronic Obstructive Lung Disease (GOLD) • http://www.goldcopd.com/Index.asp • 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.

6. The Diagnosis of COPD EXPOSURE TO RISK FACTORS SIGNS SYMPTOMS cough Hyperinflation Prolonged expiration tobacco sputum occupation dyspnea Reduced BS indoor/outdoor pollution è SPIROMETRY

7. FEV1 / FVC < 70% 50% < FEV1< 80% FEV1 / FVC <70% 30%< FEV1 <50% GOLD Guidelines: Classifications Symptoms Severity Spirometry Treatment Normal Education, avoidance of risk factors, Pneumovax/flu vaccine At RiskStage 0 +/- Chronic cough, sputum FEV1 / FVC <70% MildStage I +/- Chronic cough, sputum Add short-acting bronchodilator p.r.n. FEV180% predicted ModerateStage II +/- Chronic cough, sputum, dyspnea Add regular treatment with one or more LABD Rehabilitation SevereStage III +/- Chronic Cough, sputum, dyspnea Add ICS if repeated exacerbations Very Severe Stage IV Chronic respiratory failure or cor pulmonale FEV1 / FVC <70% FEV1<30% 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.

8. 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)

9. 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

10. 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.

13. 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

14. 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

15. 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

17. 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.

20. http://www.azcert.org/

21. 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.

22. Hyperprolactinemia • Asymptomatic • Gynecomastia • Galactorrhea • Oligo- or amenorrhea • Sexual dysfunction • Acne • Hirsutism • Infertility • Loss of bone mineral density

24. 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.

26. 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.

31. 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

32. 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

33. 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.

34. Common Tongue Conditions in Primary Care

35. 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.

36. 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)

38. Universal Precautions in Pain Management • Risk stratification • Medication agreement or pain contract • Adherence monitoring • Urine drug screening

39. 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

40. 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

46. 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.

47. 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.

48. 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