Careyva, Beth, MD

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Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of Family Medicine2014- 2015 Clinical Guidelines andRecommendationsBeth Careyva MDLehigh Valley Health Network, beth_a.careyva@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/family-medicinePart of the Medical Specialties CommonsThis Presentation is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works byan authorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtCareyva, B. (2015, July 29). 2014-2015 Clinical Guidelines and Recommendations. Presentation presented at: The Chesapeake SummerEscape CME Conference, Cambridge, MD.2014 - 2015 Clinical Guidelines and Recommendations PAFP Summer CME Conference Beth Careyva, MD July 29, 2015 Objectives  Review recommendations from recently published clinical guidelines  Discuss implications for clinical practice using a case-based approach   Guidelines for Review     American Diabetes 2015 Standards of Care  USPSTF Screening for Thyroid Dysfunction  USPSTF Screening for Carotid Artery Stenosis   American College of Physicians Diagnosis of OSA  American Academy of Pediatrics Fluoride Use in Children  Advisory Committee on Immunization Practices Pneumococcal Immunization Updates   American Diabetes 2015 Standards of Care  Section 2: Classification and Diagnosis of Diabetes   BMI cut point for screening overweight and obese Asian Americans for prediabetes and type 2 diabetes changed from 25 kg/m2  to 23 kg/m2 Section 4: Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care, and Immunization  Limit time spent being sedentary to < 90 minutes at a time  E-cigarettes not supported as an alternative to smoking   Immunization recommendations updated to include recommendations for PCV13 and PPSV23 Section 6: Glycemic Targets  Fasting blood glucose target: 80-130 mg/dL    (previously 70-130 mg/dL)   New recommendations to assess readiness for continuous glucose monitoring (CGM)  Section 7: Approaches to Glycemic Treatment  Algorithm updated to reflect all currently available therapies  FDA Approved DM2 Medications  SGL2 Inhibitors  Dapagliflozen (January 2014)  Empagliflozen (August 2014)   GLP1 Receptor Agonists   Abliglutide (April 2014)  Dulaglutide (April 2014) Section 8: Cardiovascular Disease and Risk Management  Diastolic blood pressure goal: 90 mmHg for most people with diabetes and hypertension    Statin treatment recommendations based on 2013 American College of Cardiology/American Heart Association guidelines   Screening lipid profile recommended at diagnosis, age 40, and “periodically thereafter” Section 9: Microvascular Complications and Foot Care  Foot exam at every visit for patients with insensate feet, foot deformities, or a history of foot ulcers  Section 11: Children and Adolescents  A target A1c of <7.5% is recommended, though individualization is encouraged  Section 12: Management of Diabetes in Pregnancy  New section with recommendations related to pregnancy and diabetes, including preconception counseling, medications, blood glucose targets, and monitoring JM  74 year old female  PMH: DM2, HTN, HL, osteoporosis  Medications: metformin, glipizide, lisinopril, atorvastatin, ibandronate, calcium/vitamin D  3 month follow up visit    JM  Fasting blood glucose log  Date Fasting Blood Glucose  June 1 72 June 2 104 June 3 79 June 4 97 June 5 81 What would you do next? (choose all that apply) A) Tell her that her diabetes is very well controlled B) Review signs/symptoms of hypoglycemia C) Discontinue glipizide D) Discontinue metformin and glipizide  What would you do next? (choose all that apply) A) Tell her that her diabetes is very well controlled B) Review signs/symptoms of hypoglycemia C) Discontinue glipizide D) Discontinue metformin and glipizide  Summary   Diastolic blood pressure and cholesterol guidelines updated  Lower end of fasting blood glucose target adjusted to 80 mg/dL  Focus on individualization and patient-centered care USPSTF Screening for Thyroid Dysfunction U.S. Preventive Services Task Force 2015 Recommendation  U.S. Preventive Services Task Force 2004 Recommendation  USPSTF Screening for Carotid Artery Stenosis  U.S. Preventive Services Task Force 2014 Recommendation  U.S. Preventive Services Task Force 2007 Recommendation  American College of Physicians Diagnosis of OSA  Recommendation 1: ACP Recommends a sleep study for patients with unexplained daytime sleepiness   Grade: weak recommendation, low-quality evidence Recommendation 2: ACP recommends polysomnography for diagnostic testing in patients suspected of obstructive sleep apnea.  ACP recommends portable sleep monitors in patients without serious comorbidities as an alternative to polysomnography when polysomnography is not available for diagnostic testing.  Grade: weak recommendation, moderate quality evidence  ACP Recommendations for OSA  Increased emphasis on diagnostic testing for unexplained daytime sleepiness   Portable monitors may be used in low risk patients   Utility of portable monitors for diagnosing OSA in patients with comorbid conditions, such as CHF or COPD, unknown  Case: SJ   34 year old female  PMH: obesity, gestational diabetes   SH: Lives with husband and 1 year old child  “I feel so tired during the day, even when I get a lot of sleep.” Case: SJ TSH, CBC, and Lyme’s tests all normal  Sleep hygiene has not decreased fatigue  What would you do next? A) Order a sleep study B) Tell her to drink more coffee C) Encourage close follow up and consider further testing if symptoms progress or do not improve What would you do next? A) Order a sleep study B) Tell her to drink more coffee C) Encourage close follow up and consider further testing if symptoms progress or do not improve Daytime Sleepiness   Sleep study warranted for unexplained daytime sleepiness Sleepcenter.org American Academy of Pediatrics Fluoride Use in Children   Dental caries are the most common chronic disease of childhood Caries (acid produced by bacteria erodes tooth enamel) are preventable  Fluoride has proven effectiveness to decrease dental caries Fluoride Modalities Fluoride Use in Caries Prevention  Perform oral health risk assessments on all children beginning at 6 months of age  Assess a child’s exposure to fluoride and determine the need for supplements  Understand indications for fluoride varnish  Advocate for water fluoridation in the local community  Oral Health Risk Tools Available Brightfutures.aap.org Advisory Committee on Immunization Practices Pneumococcal Immunization Updates  www.eziz.org Advisory Committee on Immunization Practices - Recommendations for PCV13 Vaccine All adults 65 years of age or older receive a dose of PCV13 followed by a dose of PPSV23 6-12 months later Adults over age 65 who have already received PPSV23 at age 65 and older can have PCV13 in 12 months  Recommendations for Age 65 or Older  www.eziz.org Recommendations for Age 19 or Older  www.eziz.org Case: RM   67 year old female  PMH: DM2, HTN, HL  Received PPSV23 7 months ago “I just saw a commercial about some other pneumonia shot.” What would you tell her? A) You have already been immunized for pneumonia and do not need another vaccine B) You can receive PCV13 today C) You should return in 5 months for PCV13 What would you tell her? A) You have already been immunized for pneumonia and do not need another vaccine B) You can receive PCV13 today C) You should return in 5 months for PCV13 Case   37 year old male  PMH: Seasonal Allergies, Current smoker What would you tell him? A) He doesn’t meet criteria for either pneumonia vaccine B) He should have the new pneumonia vaccine, PCV13, followed by PPSV23 in one year C) He should be immunized with PPSV23 today D) He should have PPSV23 today, followed by PCV13 in one year  What would you tell him? A) He doesn’t meet criteria for either pneumonia vaccine B) He should have the new pneumonia vaccine, PCV13, followed by PPSV23 in one year C) He should be immunized with PPSV23 today D) He should have PPSV23 today, followed by PCV13 in one year  Summary   Minimum FBG target changed to 80 mg/dL  Sleep studies recommended for those with unexplained daytime sleepiness  Oral health risk tools and fluoride may help prevent dental caries  Patients over the age of 65 need PPV13 and PPSV23 References  1. American Diabetes Association. Standards of Medical Care in Diabetes- 2015. Diabetes Care.2015;38:S1-S93. 2. LeFevre ML. Screening for thyroid dysfunction: U.S. Preventive Services Task Force Recommendation Statement. Annals Intern Med.2015;162(9):641-651. 3. LeFevre ML. Screening for asymptomatic carotid artery stenosis: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med.2014;161(5):356-362. 4. Qaseem A, Dallas P, Owens DK, et al. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med.2014;161:210-220. 5. Clark MB, Slayton RL. Fluoride use in caries prevention in the primary care setting. Pediatrics.2014;134:626-633.  6. Tomczyk S, Bennett NM, Stoecker C, et al. Use of PCV-13 and PPSV-23 among adults age 65 and older: recommendations of the ACIP. MMWR.2014;63(37):822-825.    

2014- 2015 Clinical Guidelines and Recommendations

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2014- 2015 Clinical Guidelines and Recommendations

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Lehigh Valley Health Network: LVHN Scholarly Works