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J . T H O M A S C R O S S , J R . , M D , M P H , F A A P , F A C P P R E S I D E N T , A - C R O S S M E D I C I N E R E V I E W S
C O L O R A D O S P R I N G S , C O I M M E D I A T E P A S T C H A I R , M E D - P E D S S E C T I O N O F A A P
J O I N T A A P S E C T I O N O N S E N I O R M E M B E R S / M E D - P E D S W E B I N A R
M A R C H 4 , 2 0 1 4
Health Issues/Controversies Affecting ALL Seniors
Health Issues/Controversies Affecting ALL Seniors
Disclosure: “Neither Dr. Tommy Cross nor Dr. J. M. Aronson have any relevant financial relationships with the manufacturers of any commercial products or providers of commercial services discussed in this webinar.” Dr. Cross does not intend to discuss any unapproved/investigative use of a commercial product/device in his presentation.
Disclaimer: Statements and opinions expressed during this webinar are those of the moderator and the speaker and not necessarily those of the AAP Section on Senior Members or the American Academy of Pediatrics.
Tommy Cross MD
Tulane Medical School Board certified by the American Board of
Medical Specialties in Internal Medicine, Pediatrics, Adult Infectious Diseases, and Pediatric Infectious Diseases.
Former Associate professor in the Department of Internal Medicine and Pediatrics at Louisiana State University Health Sciences Center.
Clinical Efficacy Subcommittee of the American College of Physicians, which writes and directs the formulation of ACP guidelines for Internists. (Former)
ACP’s Performance Measurement Committee (current)
Past President – AAP Section Med-PEDS President – Medical Education Company, home
care and “free” clinics
Senior Health: Outline and Objectives Discuss the new lipid guidelines
Are seniors being “overtreated”? What is the best drug to take? How to calculate your cardiac risk.
Review the new Hypertension guidelines What are the best drugs to take? Are drugs always necessary? What if I have diabetes?
I or my significant other has erectile dysfunction. Should I/they be evaluated for Low-Testosterone? What is the data? What are the effective treatments? What are the side-effects?
GoToWebinar Housekeeping: What You See
GoToWebinar Housekeeping: Attendee Participation
GoToWebinar Housekeeping: Time for Questions
NCEP’s ATP III Update Recommendations—Valid until 11/2013 This is what we used to do! Add up all these!
Risk Factor Assessment Framingham 10-year Risk Assessment (Use calculator) Then “count” the following:
Age (males ≥ 45 and females ≥ 55) FH premature CHD in 1st degree relative (males ≤ 55 and females ≤ 65) Current cigarette smoking Hypertension (≥ 140/90 or on medication) HDL ≤ 40 CHD “risk equivalents”
PAD AAA TIA or CVA or carotid stenosis DM 10 Y CHD risk ≥ 20% CKD
Perform a Fasting Lipid Panel Then determine LDL “target” and assess value that should be treated with drugs.
NCEP’s ATP III Update Recommendations
Risks & Risk Assessment
LDL Goal Treat with Drugs Non-HDL Goal
CHD & CHD Risk
Equivalents
< 100 (< 70 optional)
≥ 100 < 130 (< 100 optional)
2+ Risk Factors & 10-Y CHD 10-20%
< 130 (< 100 optional)
≥ 130 < 160 (<130 optional)
2+ Risk Factors & 10-Y CHD < 10%
< 130 ≥ 160 < 160
0-1 Risk Factors < 160 ≥ 190
2013 ACC/AHA Lipid Guidelines
11/2013: American Heart Association/American College of Cardiology Cardiovascular Risk Guideline Blood Cholesterol Guideline Obesity Guideline Lifestyle Management Guideline
2013 ACC/AHA Guidelines
Disclosures of “Relationships with Industry and Other Entities” 17 Work Group Members: “primary care, cardiologists, endocrinologist, experts in
lipidology, clinical trials, CV epidemiology, and guideline development” 5/17 with disclosures
Poll Question #1
66 YO white male presents for annual evaluation. No signficant PMH. Has hypertension and is on lisinopril 20 mg daily. FH: AMI, mother, age 52 YO VS: Afebrile, 110/75, HR 70 Normal PE. Screening labs: A1c 5.2%; normal chemistry and CBC TC 210 TG 95 HDL 37 LDL 160
Poll Answer Choices #1 - Which of the following is most appropriate?
1. Count his risk factors (male, etc.) and determine target LDL 2. Prescribe a statin to reduce his Total Cholesterol to < 190 3. Start fish oil to reduce his LDL 4. Use the Pooled Cohort Risk Assessment to calculate 10Y risk
VOTE NOW 15 Seconds…
CLOSE POLL
Poll Question #1 - Review
66 YO white male presents for annual evaluation. No signficant PMH. Has hypertension and is on lisinopril 20 mg daily. FH: AMI, mother, age 52 YO VS: Afebrile, 110/75, HR 70 Normal PE. Screening labs: A1c 5.2%; normal chemistry and CBC TC 210 TG 95 HDL 37 LDL 160
Poll Answer Review #1 - Which of the following is most appropriate?
1. Count his risk factors (male, etc.) and determine target LDL 2. Prescribe a statin to reduce his Total Cholesterol to < 190 3. Start fish oil to reduce his LDL 4. Use the Pooled Cohort Risk Assessment to calculate 10Y risk
Poll Question #2
68 year-old female with no PMH presents for evaluation of fatigue. ROS negative. PMH: Negative No meds VS: Afebrile, 110/75, HR 70 Normal exam Labs: Normal chemistry and CBC TC 230 TG 275 HDL 27 LDL 175
Poll Answer Choice #2 - Which of the following is most appropriate?
A. Start fish oil B. Start simvastatin 20 mg QHS C. Start atorvastatin 40 mg QHS D. Start niacin E. Check TSH and UA
VOTE NOW 15 Seconds…
CLOSE POLL
Poll Question #2 - Review
68 year-old female with no PMH presents for evaluation of fatigue. ROS negative. PMH: Negative No meds VS: Afebrile, 110/75, HR 70 Normal exam Labs: Normal chemistry and CBC TC 230 TG 275 HDL 27 LDL 175
Poll Answer Review #2 - Which of the following is most appropriate?
A. Start fish oil B. Start simvastatin 20 mg QHS C. Start atorvastatin 40 mg QHS D. Start niacin E. Check TSH and UA
2013 ACC/AHA Management of Blood Cholesterol
Major Changes Treatment decisions now based on 10-year risk assessment only. Treatment no longer targets a specific LDL.
Counting risk factors = Out
2013 ACC/AHA Cardiovascular Risk
Use Pooled Cohort Equation for calculation of 10Y risk Available at ACC/AHA website within 2013 guidelines (spreadsheet) Overwhelming drive to identify the low-risk guy who drops dead of CVD Getting lots of criticism…
For primary prevention, 40 – 79 YO. Assess traditional Risk Factors and calculate 10Y risk Q 4-6 Y
Traditional Risk Factors = age, sex, T. chol, HDL-c, SBP, anti-HTN Rx, DM, smoking
Available at: http://www.cardiosource.org/science-and-quality/practice-guidelines-and-quality-standards/2013-prevention-guideline-tools.aspx
This is the Pooled Cohort Equation Calculator with an example: 68 y/o woman who has HTN and total cholesterol of 210
GROUP RECOMMENDATION DRUG
Secondary Prevention High Intensity Statin
Atorva- 40 – 80 mg Rosuva- 20 mg
Primary Prevention
≥ 21 YO, LDL > 190 High Intensity Statin
Atorva- 40 – 80 mg Rosuva- 20 mg
40 – 75 YO, LDL 70-189, 10Y risk ≥ (5.0% - ) 7.5%
Moderate or
High Intensity Statin
Simva- 20 – 40 mg Prava- 40 mg Lova- 40 mg Atorva- 20 – 80 mg Rosuva- 10 – 20 mg
40 – 75 YO, LDL 70 – 189, Diabetic,
10Y risk ≥ 7.5%
High Intensity Statin
Atorva- 40 – 80 mg Rosuva- 20 mg
40-75 YO, LDL 70-189, Diabetic,
10Y risk < 7.5%
Moderate Intensity Statin
Simva- 20-40 mg Prava- 40 mg Lova- 40 mg Atorva- 20 mg Rosuva- 10 mg
2014: What Do We Actually DO?
If > 75 YO, for both primary and secondary prevention: Consider comorbidities, drug-drug interactions, and patient preferences Options:
Con’t current statin, if doing okay. Prescribe moderate intensity statin. Do not prescribe any statin.
Trouble with Statins
Hepatitis Myalgias/myopathy (even rhabdomyolysis) Impaired cognition Diabetes Proportional to intensity of statin “Adverse outcome of incident diabetes must be weighed in context of potentially fatal
or debilitating occurrence of MI or stroke that could be prevented by statin.” “It’s worth it!” point of view. “Occurrence of major CVD event represents a much greater harm than an increase in blood
glucose”
Interesting Assessment
“Here’s one bright spot with the near simultaneous publication of these new guidelines: They will clearly wreak havoc on the quality indicator mafia. Pay for performance? Try calculating the individualized LDL target now and dinging me on that basis. It won’t be easy.” December 30, 2013 By: PAUL J. HAUPTMAN Family Practice News
Hypertension JNC VIII Guidelines
Poll Question #3
Based on JNC VIII, which of the following values on the next slide is correct in regards to when someone ≥ 60 years of age should be started on pharmacologic therapy?
Poll Answer Choice #3--Which of the following is most appropriate?
A. When their BP is ≥ 140/90? B. When their BP is ≥ 140/90 after lifestyle modifications have been
implemented? C. When their BP is ≥ 150/90? D. When their BP is ≥ 150/90 after lifestyle modifications have been
implemented?
VOTE NOW 15 Seconds…
CLOSE POLL
Poll Answer Review #3--Which of the following is most appropriate?
A. When their BP is ≥ 140/90? B. When their BP is ≥ 140/90 after lifestyle modifications have been
implemented? C. When their BP is ≥ 150/90? D. When their BP is ≥ 150/90 after lifestyle modifications have been
implemented?
Hypertension JNC VIII (2013)
Recommendation 1 (Note ages here!) In the general population aged ≥ 60 years, initiate pharmacologic treatment to
lower blood pressure (BP) at systolic blood pressure (SBP) ≥ 150 mm Hg or diastolic blood pressure (DBP) ≥ 90 mm Hg and treat to a goal SBP < 150 mm Hg and goal DBP < 90 mm Hg. (Strong Recommendation – Grade A)
Corollary Recommendation In the general population aged ≥ 60 years, if pharmacologic treatment for high BP
results in lower achieved SBP (eg, < 140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion – Grade E)
Note that in this patient population, no evidence that going lower than a DBP of 80-85 makes any difference! And we know if you go too low it is harmful!
Poll Question #4 - Hypertension JNC VIII Treatment
A 68 year-old Caucasian woman with diabetes presents with a BP of 166/98.
Poll Question #4 – Answer Choices
Which of the following anti-hypertensives should she start?
A. Thiazide-like diuretic B. ACE-inhibitor C. Angiotensin receptor blocker (ARB) D. Calcium-channel blocker E. Any of the above choices is acceptable according to JNC VIII
VOTE NOW 15 Seconds…
CLOSE POLL
Poll Question Review #4 - Hypertension JNC VIII Treatment
A 68 year-old Caucasian woman with diabetes presents with a BP of 166/98.
Poll Answer Review #4
Which of the following anti-hypertensives should she start?
A. Thiazide-like diuretic B. ACE-inhibitor C. Angiotensin receptor blocker (ARB) D. Calcium-channel blocker E. Any of the above choices is acceptable according to JNC VIII
What to Start With?
Non-Blacks: including those with diabetes, start a thiazide diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB).
Blacks: including those with diabetes, start a thiazide diuretic or CCB.
The panel did NOT recommend β-blockers for the initial treatment of hypertension because of higher rate of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke compared to use of an ARB, a finding that was driven largely by an increase in stroke.
NOW WAIT A MINUTE
What about diabetics and use of ACE-inhibitors???
What about patients ≥ 75 years old with CKD?….there is no data on ACE-inhibitors being better for these patients…therefore a diuretic or CCB may be better…(Especially in light of good data with thiazides being protective for stroke in this patient population).
Testosterone Clinical Guidelines
Testosterone therapy in men with androgen deficiency syndromes Endocrine Society, 2011
Medical guidelines for clinical practice for evaluation and treatment of hypogonadism American Association of Clinical Endocrinology, Update 2002
Hypogonadism
Consider diagnosis only if: Consistent symptoms and signs
And Unequivocally low serum testosterone levels
Morning total testosterone level; reliable assay Confirm low values with repeat test Evaluate using normal ranges for your lab
Do not measure during acute or subacute illness Do not screen the general population Definitely screen certain populations
Testosterone Levels
Levels are very controversial, especially in the elderly! “Panelists disagreed on serum T levels below which therapy should be offered to older
men with symptoms.” Treat T < 280 – 300 ng/dL (healthy, young men levels) Observational studies show symptoms may be attributable to low T
Treat T < 200 ng/dL RCTs show lack of treatment effects with pretreatment T > 300
Everybody agrees that levels ~ 150 ng/dL are pathologic.
Clinical Manifestations
SPECIFIC SIGNS AND SYMPTOMS Incomplete or delayed sexual development: Clinical
history Low libido and sexual activity
Decreased spontaneous erections Sore breasts, gynecomastia
Alopecia and reduced shaving habits < 5 mL testicles (or shrinking ones . . .)
Infertility or low/zero sperm count Low-trauma fractures, osteopenia, loss of height
Hot flashes, sweats
Clinical Manifestations
OTHER SIGNS AND SYMPTOMS Low energy, motivation, confidence
Melancholy, depressed mood Difficulty concentrating and poor memory
Sleep disturbances Anemia (normochromic, normocytic; mild)
Lack of strength; reduced muscle Increased fat
What Do I Order?
Total testosterone (early a.m.) + FSH and LH Secondary: ↓ T, low or low-nl FSH and LH
Assess etiology, so consider: Serum Fe, TIBC, ferritin Prolactin, other studies of pituitary function, MRI (headaches, VF defects, T < 150, other
symptoms of hypopituitarism) Polysomnogram ROS-based assessment for infiltrative diseases (e.g., sarcoidosis, HIV, tuberculosis)
Primary: ↓ T, ↑ FSH and LH Karyotype +/- seminal fluid analyses
Major Options for Treatment
FORMULATION DOSING NOTES
Injections 150 – 200 mg Q 2 W or 75 – 100 mg Q week
Quick, high (supraphysiologic) peaks (“high”) (hypogonadal) troughs Controlled substance
1% gel Sachets, tubes, and pumps 50 – 100 mg T QD
Less peaks/troughs Less “high” with dosing More physiologic dosing Ease of application Potential for transfer
Transdermal patch 5 – 10 mg T QD Less peaks/troughs Less “high” with dosing More physiologic dosing Ease of application Some patients need two patches
“Recommend against a general policy of offering T therapy to all older men with low T levels.”
Testosterone Products: Drug Safety Communication – FDA Investigating Risk of Cardiovascular Events
Recent Issue: January, 2014
RECOMMENDATION: At this time, FDA has not concluded that FDA-approved testosterone treatment increases the risk of stroke, heart attack, or death
Erectile Dysfunction
Erectile Dysfunction (ED) - Etiology
Vascular (MOST COMMON!): Diabetes, other PVD
Neurogenic: Diabetes, peripheral neuropathy Hypogonadism (low testosterone): Low libido along with ED Medications: Beta-blockers, diuretics Psychogenic: Associated with
acute onset, may be partner-specific, depression
Erectile Dysfunction Therapy
Sildenafil (Viagra®), vardenafil (Levitra®), tadalafil (Cialis®), and avanafil (Stendra™) are phosphodiesterase-5 inhibitors (PDE-5) All contraindicated with nitrates and alpha-adrenergic blockers
Except tamsulosin, OK with tadalafil Blue vision (3%): Sildenafil (cross-reacts with PDE-6
in the retina) Back pain (6%): Tadalafil Tadalafil now approved for daily use Recent warnings show risk of hearing loss
Penile injections: Alprostadil, papaverine, phentolamine Vacuum device: Safe but time-consuming Intraurethral alprostadil (MUSE®): Safe Penile implants: Use only after other therapy
Poll Question #5
A 67-year-old man presents for treatment of erectile dysfunction. He has had problems sustaining erections for the past year. He has a normal libido. Meds: Simvastatin, omeprazole, isosorbide mononitrate, lisinopril, aspirin.
Poll Answer Choice #5- What would you recommend?
1. An intraurethral med such as alprostadil (MUSE®) 2. An oral med such as Sildenafil (Viagra®) 3. Testosterone patch (Androderm®, Testoderm® TTS) 4. Referral for penile implant 5. Psychotherapy
VOTE NOW 15 Seconds…
CLOSE POLL
Poll Question Review #5
A 67-year-old man presents for treatment of erectile dysfunction. He has had problems sustaining erections for the past year. He has a normal libido. Meds: Simvastatin, omeprazole, isosorbide mononitrate, lisinopril, aspirin.
Poll Answer Review #5- What would you recommend?
1. An intraurethral med such as alprostadil (MUSE®) 2. An oral med such as Sildenafil (Viagra®) 3. Testosterone patch (Androderm®, Testoderm® TTS) 4. Referral for penile implant 5. Psychotherapy
Time for Q & A
Before we start, let’s review how you can ask a question! Dr. Cross – next slide please!
GoToWebinar Housekeeping: Time for Questions
Question # 1
Moderator conclusion: Thank You – Dr. Cross, Tracey Coletta, and AAP Reminders: Webinar Evaluation Questionnaire (hyperlink) will come
via email. Please respond. Future Topics??? Webinar On Demand plus presentation and
resources available on SOSM website at www.aap.org/seniors in 24-72 hours. Tell your colleagues! SOSM “new look “website at www.aap.org/seniors
Thank you and Good Bye Tommy Cross MD
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