**Update as of August 2011:
New clinical guideline issued on diagnosis, management of stable COPD August,
2011
Several collaborating medical societies, including the American College of
Physicians (ACP), released new guidelines this on the diagnosis and
management of stable chronic obstructive pulmonary disease (COPD).
The guideline, which updates and expands on a 2007 ACP guideline on this
topic, was developed by a panel with members from ACP, the American College of
Chest Physicians, the American Thoracic Society, and the European Respiratory
Society, and represents an official, joint guideline from all four
organizations.
This guideline addresses the value of history and physical examination for
predicting airflow obstruction; the value of spirometry for screening or
diagnosis of COPD; and COPD management strategies, specifically evaluation of
various inhaled therapies (anticholinergics, long-acting â-agonists, and
corticosteroids), pulmonary rehabilitation programs, and supplemental oxygen
therapy.
The guideline was published in the Aug. 2 Annals of Internal Medicine.
**Update as of February 2012:
Update to Diabetes Volume 6 of Edition 7 Chapter 3 Diabetes Management
A physician from University of Pennsylvania wrote the editors to note that,
“…it would be important to include findings from the 2008 NEJM Holman
article which reports the 10 yr follow-up to the original 10-yr 1998
UKPDS study (which was referenced in the case write-up). These findings
show that there is a mortality benefit to early tight control in this
group of patients, not only a preserved reduction in macrovascular
disease and mortality in the metformin arm, but also a post-trial risk
reduction in diabetes-related death and MI in the SU-insulin arm.
It is just another way to emphasize to learners that being aggressive
early, e.g. in newly diagnosed patients, does lead to benefit down
the road in a "legacy effect" manner, and that this is a different
group of patient than what ACCORD, ADVANCE, and VADT were studying.”
Our chapter author responds, “I agree that “being aggressive early,
e.g. in newly diagnosed patients, does lead to benefit down the road
in a "legacy effect" manner” is an intriguing hypothesis, and could
well turn out to be the case.
UKPDS studied newly-diagnosed diabetics in the 1970s thru early 1990s.
These patients were not treated to current blood pressure or LDL goals.
They were randomized to intensive versus conventional treatment
(initiate treatment when the fasting glucose was above 108 mg/dL or 270 mg/dL).
Patients were followed for 10 years, and about a 1-point separation in A1c
was achieved (on average 7.0 versus 7.9, but with steady increase over time
such that at 10 years median A1c was high 7s versus high 8s). The larger
study, in which a sulfonurea-insulin based regimen was used, microvascular
complications (but not mortality or macrovascular disease) were reduced.
After completion of the trial (median 10 years), the surviving cohort
was followed – for a median period of 8.5 years; standardized data
collection was performed only for the first 5 post-trial years.
Differences in A1c were lost by 1 year post-trial. Post-hoc analyses
found that post-trial risk reductions emerged in the sulfonylurea–insulin
group for myocardial infarction (15%, P=0.01), and death from any cause
(13%, P=0.007). This is not RCT data – it is follow-up of a cohort
that was in an RCT and for whom data is no longer being collected
in a standardized manner and post-hoc analyses are being pursued.
It is not clear why RCT data has been heterogeneous, with ACCORD
showing increased mortality from intensive control (at only 3.5 years),
and other trials not showing this effect. Many think that it relates
to whether patients were enrolled at diagnosis or later in the disease,
but this is currently a hypothesis. UKPDS occurred in an era where
lipids and HTN were not managed to current standards and DM diagnosis
required a greater degree of hyperglycemia than in the current era.
Management of insulin in type 2 DM is a very broad topic, and I
chose to focus on the relevant RCT data (UKPDS, VADT, ACCORD, and ADVANCE).
The post-trial analysis of the UKPDS cohort certainly generates enthusiasm
for the hypothesis that there is a “legacy effect” (i.e. mortality
benefit of glucose control over the very long term), but I do not feel
these findings have the same weight as RCT data, especially now that
we have an RCT showing increased early mortality. If I re-wrote the
chapter, I would certainly include the findings of the 2008 post-trial report.”
The Editors of the Yale Office-based Medicine Curriculum welcome feedback
on our chapters to improve the content and quality of the discussion,
especially where the discussions are so rich.
