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Pediatrics - General Pediatrics and Adolescent Medicine
Family-based health behavior treatment for children with obesity (July 2023)
Intensive family-based health behavior and lifestyle treatment is the initial strategy to manage overweight or obesity in children, but whether this can be effectively delivered in a primary care setting is unclear. A randomized trial in 452 children ages 6 to 12 years with overweight or obesity evaluated an intervention consisting of diet, activity, and behavior change guidance delivered by a health coach in approximately 30 sessions over two years, compared with usual care.2 The intervention had modest benefits on weight outcomes for children that were sustained during the two-year intervention (treatment difference in body mass index was -6.21 percent [95% CI -10.14 to -2.29]), which is of borderline clinical significance. Nonetheless, the study provides proof of concept for a family-based intervention implemented by behaviorally trained coaches embedded in a primary care practice.
Gastroenterology and Hepatology - Small Bowel and Colonic Disease
Guidelines on chronic idiopathic constipation (July 2023)
The American College of Gastroenterology and American Gastroenterological Association updated guidelines on the management of chronic idiopathic constipation (CIC) include use of fiber as first-line therapy and the use of stimulant laxatives for short-term use and rescue therapy.3 Options for CIC refractory to over-the-counter agents include lubiprostone, linaclotide, plecanatide, and prucalopride. UpToDate's recommendations are largely consistent with these guidelines.
Cardiovascular Medicine - Valvular Heart Disease
Apixaban not adequate for On-X valve (July 2023)
The only oral anticoagulants approved for patients with mechanical valves to prevent valve-related thromboembolism and valve thrombosis are vitamin K antagonists (VKA). The On-X valve requires less intense anticoagulation than other mechanical valves, but the safety of using a direct oral anticoagulant (DOAC) for this valve has not been determined. An open-label trial randomly assigned over 800 patients with an On-X aortic valve to the DOAC apixaban 5 mg daily or VKA (target international normalized ratio 2.0 to 3.0).4 Nearly all patients were also treated with low-dose aspirin. The trial was stopped early due to excess valve-related thromboembolism/thrombosis in the apixaban group. Major bleeding rates were similar in the two groups. The findings indicate that apixaban is not an adequate anticoagulant for patients with an On-X valve.
Family Medicine - Geriatrics
Updated Beers criteria for drug prescribing in older adults (July 2023)
The Beers criteria, used to assess inappropriate drug prescribing for older adults, have been updated.1 Changes in the 2023 criteria include avoidance of: 1) rivaroxaban for long-term treatment of nonvalvular atrial fibrillation or venous thromboembolism, as well as avoidance of warfarin as initial therapy for these conditions unless alternatives are contraindicated; 2) sulfonylureas as first- or second-line monotherapy or add on-therapy; and 3) initiation of oral or transdermal estrogen in older women. The use of aspirin for primary prevention of cardiovascular disease is also discouraged, and deprescribing of aspirin in older patients already taking it for primary prevention is recommended.
1. https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372 (Accessed on June 06, 2023). [Context Link]
2. Epstein LH, Wilfley DE, Kilanowski C, et al Family-Based Behavioral Treatment for Childhood Obesity Implemented in Pediatric Primary Care: A Randomized Clinical Trial. JAMA. 2023;329(22):1947. [Context Link]
3. Chang L, Chey WD, Imdad A, et al American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation. Am J Gastroenterol. 2023;118(6):936-954. [Context Link]
4. Wang T. Apixaban or warfarin in patients with an On-X mechanical aortic valve. NEJM Evid. 2023;2(7). [Context Link]
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