What are the adverse effects of prolonged opioid use in patients with chronic pain?

Constipation, nausea, and dyspepsia are the most common long-term adverse effects of chronic opioid use (strength of recommendation [SOR]: B, systematic review of low-quality studies). Men may experience depression, fatigue, and sexual dysfunction (SOR: B, 2 observational studies). Prolonged use of opioids also may increase sensitivity to pain (SOR: C, review of case reports and case series). (This review does not address drug seeking or drug escalating.) Patients on long-term methadone are at risk for cardiac arrhythmias caused by prolonged QT intervals and torsades de pointes (SOR: C, case reports). Patients taking buprenorphine for opioid dependence may experience acute hepatitis (SOR: C, 1 case report)

Do inhaled steroids increase the risk of osteoporosis?

The use of inhaled corticosteroids at conventional doses for asthma and chronic obstructive pulmonary disease (COPD) does not appear to be associated with significant bone loss at 2 to 3 years of follow-up (strength of recommendation [SOR]: A, systematic reviews and randomized controlled trials [RCTs]). However, higher doses of inhaled corticosteroids may be associated with negative bone density changes at up to 4 years of follow-up (SOR: C, RCTs without change in fracture rates). No evidence exists to evaluate whether nasal steroids increase the risks of bone loss. Longer-term effects of prolonged use of inhaled steroids on BMD or fracture risk are undetermined with current evidence

Can infants/toddlers get enough fluoride through brushing?

Yes. Brushing twice daily with topical fluoride toothpaste decreases the incidence of dental caries in infants and toddlers (strength of recommendation [SOR]: A, based on meta-analyses of randomized controlled trials [RCTs]). High-concentration fluoride toothpaste delivers superior caries protection, but causes more dental fluorosis. Use of high-concentration fluoride toothpaste should be targeted towards children at highest risk of dental caries, such as those living in areas without fluoridated water (SOR: B)

What is the best treatment for chronic constipation in the elderly?

There is no one best evidence-based treatment for chronic constipation in the elderly. While the most common first-line treatments are dietary fiber and exercise, the evidence is insufficient to support this approach in the geriatric population (strength of recommendation [SOR]: for dietary fiber: A, based on a systematic review; for exercise: SOR: B, based on 1 good- and 1 fair-quality randomized controlled trial [RCT]). Herbal supplements (such as aloe), alternative treatments (biofeedback), lubricants (mineral oil), and combination laxatives sold in the US have not been sufficiently studied in controlled trials to make a recommendation (SOR: A, based on systematic review)

Evaluation of hip pain in older adults

The evaluation of hip pain in patients 65 years and older should include a history and physical examination, followed by pertinent imaging studies. (Strength of Recommendation [SOR]: C, based on expert opinion.) Patients who have hip pain for more than four weeks or who have concerning historical features, signs, or symptoms require hip imaging with radiography. There are no trials comparing the accuracy of magnetic resonance imaging (MRI), computed tomography (CT), and bone scintigraphy. MRI should be used in patients with suspected acute fracture in whom plain radiography does not yield a definitive diagnosis. (SOR: C, based on one small case series.) If MRI is contraindicated or unavailable, CT or bone scintigraphy can be substituted. (SOR: C, based on expert opinion.

What is the risk of bowel strangulation in an adult with an untreated inguinal hernia?

The risk of bowel strangulation is estimated to be small--less than 1% per year (strength of recommendation [SOR]: B, based on small cohort studies with short follow-up). Experts recommend repair for patients with risk factors for poor outcomes after potential strangulation. These risk factors include advanced age, limited access to emergency care, significant concomitant illness, inability to recognize symptoms of bowel incarceration, and poor operative risk (American Society of Anesthesiologists class III and IV) (SOR: C, based on expert opinion and case series). It is reasonable to offer elective surgery or watchful waiting to low-risk patients who understand the risks of strangulation (SOR: C, based on expert opinion and case series)

Do Inhaled Steroids Increase the Risk of Osteoporosis?

Inhaled corticosteroids are the primary therapy for asthma and are commonly prescribed for chronic obstructive pulmonary disease. The use of oral steroids is a well-known risk factor for osteoporosis, but the effects of inhaled corticosteroids on bone mineral density (BMD) are not well defined. No significant changes seen in BMD at moderate doses Our search found evidence pertaining to the use of inhaled pulmonary steroids, but no evidence meeting our inclusion criteria about the effect of inhaled nasal steroids. We located a Cochrane review, 1 other meta-analysis, and 2 individual RCTs that were not included in the systematic reviews. Three of the 7 RCTs included in the 2002 Cochrane review met our inclusion criteria for evaluating the impact of inhaled corticosteroids on BMD or fracture rate for adults with asthma or COPD. All 3 RCTs (792 subjects total) examined the effect of conventional doses of inhaled corticosteroids on BMD and 2 of the RCTs (892 participants total) collected fracture data. No demonstrable effect was seen on vertebral fracture (odds ratio [OR]=1.87; 95% confidence interval [CI], 0.5-7.03) or BMD at 2 years follow-up. The subjects were otherwise healthy people with asthma or COPD with an average age of 40 years; men outnumbered women 2 to 1. A fair-quality 2004 meta-analysis of 14 randomized trials (2300 participants) included 2 studies (448 subjects) that overlapped with the Cochrane review. There were no significant changes in BMD with moderately high doses of inhaled corticosteroids at 1 to 3 years follow-up. Annual changes in lumbar and femoral neck BMD (-0.23% and -0.17%, respectively) were not statistically significant. Mean changes in lumbar BMD were not significantly different from controls (-0.02). A fair-quality 2004 RCT did not demonstrate any clinically relevant effect on BMD at 2 years follow-up. This study used 800 mcg/day of fluticasone for patients with mild asthma. BMD changes found at higher doses There is, however, some evidence that higher doses of inhaled corticosteroids can result in adverse BMD changes. In a high-quality RCT of 412 participants, aged 40 to 69 years, with mild to moderate COPD, use of higher-dose triamcinolone (1200 mcg/day) was associated with decreased lumbar and femoral neck BMD over 3 to 4 years. The differences in BMD between the inhaled corticosteroids and placebo groups at the femoral neck and lumbar spine were 1.78% (P\u3c.001) and 1.33% (P=.007), respectively. However, the risk of fracture or height loss did not increase at follow-up. A large fair-quality RCT from 2001 included in both meta-analyses demonstrated a dose-related fall in BMD within the subjects over 2 years at the lumbar spine (standard deviation, 3.4%; P\u3c.010). This finding remained statistically significant after adjusting for asthma severity, but BMD changes were not different between the inhaled corticosteroids and placebo groups, However, this finding may be the result of higher oral corticosteroids use in the reference group. Limitations of these studies These studies, though, have limitations. The follow-up periods for all of these studies are less than 5 years, and thus the longer-term effects of prolonged use of inhaled corticosteroids on BMD or fracture risk cannot be determined with this evidence. Furthermore, the study populations were relatively young, with few other risk factors (they were, for example, predominantly male) than populations at highest risk for osteoporosis and fracture. These factors limit interpretation of the data for long-term inhaled corticosteroids use, particularly in populations with higher baseline osteoporosis risk-older persons with chronic lung disease who take inhaled corticosteroids for more than 2 to 3 years. We need better and longer-term studies to help advise our patients about the risks and benefits of inhaled corticosteroids therapy