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August 4, 2015 Issue


Clinical Practice Points

Medical Knowledge

Predictors of Pregnancy Outcomes in Patients With Lupus. A Cohort Study

Current recommendations regarding pregnancy in women with systemic lupus erythematosus (SLE) are based on limited data. In this large multicenter study that enrolled a multiethnic cohort of women with inactive or stable mild/moderate SLE during the first trimester, most pregnancies were uncomplicated, and fewer than 3% of women had severe SLE flares.

Use this study to:

  • Start a teaching session with a multiple-choice question. We've provided one below!
  • Generate a list of potential lupus-related complications of pregnancy with your learners. Use the information in DynaMed Plus: Lupus in Pregnancy (a benefit of your ACP membership).
  • Ask your learners how the results of this study can be helpful in counseling women with SLE about pregnancy. The accompanying editorial provides useful advice. Consider inviting a high-risk obstetrician to join your discussion.
  • Review the commonly used drugs for the management of SLE and determine whether each is safe in pregnancy. Review the FDA pregnancy categories for drugs.


Medical Knowledge
Patient Care

Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry. A Randomized, Controlled Trial

This study focused on the number of cardiac catheterizations that did not result in revascularization within 1 year and found no significant difference between coronary computed tomography angiography and radionuclide stress myocardial perfusion imaging for the evaluation of patients presenting with acute chest pain.

Use this study to:

  • Review the diagnostic algorithm for patients presenting with acute chest pain. How do your learners decide which of their patients require coronary angiography?
  • Ask your learners why the authors chose to assess the number of catheterizations that did not result in revascularization as this trial's primary end point, and why they chose to assess it at 1 year. The authors explain the rationale in the first paragraph of the “Outcomes and Follow-up” section in the Methods. Do your learners think this is a useful end point?
  • Ask a radiologist to show your team the results of a positive computed tomography angiogram. Visit your nuclear medicine department and review the results of radionuclide myocardial perfusion scans.


Interpersonal / Communication Skills
Professionalism
Systems-based Practice

Motor Vehicle Crash Fatalities in States With Primary Versus Secondary Seat Belt Laws. A Time-Series Analysis

This study of motor vehicle crash fatalities between 2001 and 2010 found that primary seat belt laws (citations can be issued to vehicle occupants for not wearing seat belts) were associated with lower fatality rates than secondary laws (citations can be issued only within the context of other traffic violations).

Use this study to:

  • Ask your learners if they ask their patients about seat belt use (in the back seat as well as the front seat). Should we be asking these questions? Do your learners make “buckling up” a rule in their own cars? Do they enforce it? Ask if they are comfortable telling others to buckle up if they do not.
  • The accompanying editorial notes that preventing motor vehicle injuries has been identified by the CDC as one of 7 “winnable battles.” Look at the full list with your team.
  • Assign each member of your team to review the CDC's information about a different winnable battle. Have each tell the rest of the team about the issue and if there are things we can do in our practices to help win the battle.


Costs of Care

Medical Knowledge
Patient Care
Systems-based Practice

Restrictions for Medicaid Reimbursement of Sofosbuvir for the Treatment of Hepatitis C Virus Infection in the United States

Hepatitis C Virus Treatment and Injection Drug Users: It Is Time to Separate Fact From Fiction

Limited Access to New Hepatitis C Virus Treatment Under State Medicaid Programs

These papers evaluate heterogeneity in policies related to the use of sofosbuvir-based therapy for hepatitis C virus infection and note variation in regulations and their differences from clinical recommendations.

Use these papers to:

  • Invite a hepatologist to discuss when he or she prescribes sofosbuvir to patients with hepatitis C virus infection. Ask what barriers there are to its use. How much does it cost? Is it cost-effective? How is that determined?
  • Ask your learners if they think this expensive drug should be used for the treatment of injection drug users. Why or why not?
  • Ask what the advantages and disadvantages are to having state-by-state versus national rules for the use of drugs.


Medical Knowledge

In the Clinic:

Hyponatremia

This eminently practical review explains the maintenance of normal plasma sodium levels, symptoms of hyponatremia, its evaluation and management, and more.

Use this review to:

  • Review the evaluation of patients with hyponatremia. What studies are useful, and when?
  • Teach at the bedside: Ask your learners how they assess volume status. Then, assess the volume status of your patients together on morning rounds.
  • Ask how the management of hyponatremia differs according to the patient's volume status.
  • Review the harms of hyponatremia and when patients are at the greatest risk.
  • Ask how frequently patients with hyponatremia should be monitored during its treatment. Why?
  • Download the teaching slides to help prepare a teaching session. Use the multiple-choice questions at the end to introduce topics as you teach, and log on to enter the answers to claim CME credit for yourself!


Humanism and Professionalism

Professionalism

On Being a Doctor: First Code

Christos Theophanous describes his reactions after helping out in his first “code.”

Use this essay to:

  • Listen to an audio recording of this piece with your learners, read by Dr. Michael LaCombe, Annals Associate Editor for On Being a Doctor.
  • Ask your learners if they can remember their first code. What do they recall feeling?
  • Do they still feel that way after a code? What do changes in how we react to such events as we gain experience say about who we are? Do they represent good or bad things in our development as physicians? What can we do to avoid the bad things?


mksap16

A 22-year-old woman seeks preconception counseling and treatment of recently diagnosed systemic lupus erythematosus. She reports fatigue and hand pain accompanied by morning stiffness lasting 15 minutes.

On physical examination, vital signs are normal. Malar erythema is noted. There is tenderness of the proximal interphalangeal joints bilaterally; no other synovitis is present. Recent ophthalmologic examination findings, including visual fields, are normal.

Laboratory studies

Leukocyte count 3300/µL (3.3 × 10^9/L), with an absolute lymphocyte count of 1200/µL (1.2 × 10^9/L)
C3 Normal
C4 Decreased
Serum creatinine Normal
Antinuclear antibodies Titer of 1:160 (homogeneous pattern)
Anti–double-stranded DNA antibodies Positive
IgG-specific anticardiolipin antibodies Positive
Urinalysis Normal

Which of the following is the most appropriate treatment?

A. Azathioprine
B. Hydroxychloroquine
C. Mycophenolate mofetil
D. Prednisone
E. No treatment at this time

Correct Answer
B. Hydroxychloroquine

Key Point
Although hydroxychloroquine is a pregnancy category C medication, this agent is relatively safe in pregnancy and can reduce lupus flares without harm to the fetus.

Educational Objective
Manage systemic lupus erythematosus in a patient considering pregnancy.

Treatment with hydroxychloroquine is indicated for this patient with systemic lupus erythematosus (SLE). Although hydroxychloroquine has been used anecdotally for many years in patients with SLE, numerous recent studies document significant benefits of this agent. High levels of evidence show that hydroxychloroquine prevents lupus flares and increases survival in patients with SLE; there also is moderate evidence suggesting protection against irreversible organ damage, thrombosis, and bone mass loss. Hydroxychloroquine should be continued indefinitely to prevent disease reactivation, even if the disease has been quiescent for many years. This patient has mild SLE without evidence of significant internal organ involvement; she is also trying to conceive, which further impacts choice of medication. Although hydroxychloroquine is a pregnancy category C medication, expert consensus states that this agent is relatively safe in pregnancy, and studies support a reduction in flares without harm to the fetus. Given the demonstrated benefits of hydroxychloroquine in patients with SLE, which are suggested to be time-dependent, it is appropriate to treat this patient at this time, unless the patient refuses or has a contraindication to therapy. Pregnancy outcomes in patients with SLE are better in the absence of active disease, and patients should be counseled to wait to try to conceive until they have had quiescent disease for a minimum of 6 months.

Azathioprine and mycophenolate mofetil have a steroid-sparing effect and have been shown to improve outcomes in patients with severe SLE, particularly those with kidney involvement. Azathioprine, but not mycophenolate mofetil, is generally considered the most acceptable of these agents for use during pregnancy, despite its pregnancy category D rating. This patient does not have severe disease and is not currently taking corticosteroids; therefore, treatment with these medications is not indicated.

This patient is stable with minimal disease activity, both clinically and serologically; therefore, there is no indication for treatment with prednisone unless her symptoms worsen. Prednisone, when necessary, is considered relatively safe for use in pregnancy; about two thirds of the active drug is metabolized by placental enzymes to an inactive form, limiting the amount of fetal exposure.

Bibliography
Ruiz-Irastorza G, Ramos-Casals M, Brito-Zeron P, Khamashta MA. Clinical efficacy and side effects of antimalarials in systemic lupus erythematosus: a systematic review. Ann Rheum Dis. 2010;69(1):20-28. PMID: 19103632

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.



From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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