Straight from the Heart: Medical Uptodate Year Roundup 2017

·         Elvitegravir-cobicistat use during pregnancy: For HIV-infected women who become pregnant while on an elvitegravir-cobicistat-containing regimen switch to a different regimen (1,2).

·         Acetylcysteine IV or oral does not prevent contrast nephropathy (3).

·         Frequency for dosing of oral iron for individuals with iron deficiency should be every other day rather than every day (4).

·         Patients ≥60 years of age with new onset dyspepsia should undergo an upper endoscopy (5).

·         Patients <60 years with new onset dyspepsia upper GI endoscopy is reserved for those with clinically significant weight loss, overt gastrointestinal bleeding, more than one alarm feature, or rapidly progressive alarm features. These patients should be tested and treated for H. pylori infection (5).

·         For patients with suspected multiple myeloma do cross-sectional imaging (low-dose CT, PET/CT, or MRI scan), rather than a skeletal survey, as the imaging modality to detect bone involvement (6).

·         For patients age ≤60 years with an embolic-appearing cryptogenic ischemic stroke who have a patent foramen ovale with a right-to-left shunt detected by saline contrast bubble study go for percutaneous PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone (8,9).

·         For patients with RAS/BRAF wild-type (wt) metastatic colorectal cancer (mCRC) and a left-sided primary tumor, treat with an antibody targeting the epidermal growth factor receptor (EGFR), rather than bevacizumab, when a biologic agent is chosen as a component of first-line therapy (10).

·         For most patients with RAS/BRAF wt mCRC and a right-sided primary tumor treat with bevacizumab rather than an anti-EGFR antibody in conjunction with first-line chemotherapy (10).

·         In mild to moderate treatment resistant major depression augment the initial antidepressant with a second drug and/or psychotherapy, rather than other strategies such as switching antidepressants or switching from pharmacotherapy to psychotherapy (11).

·         For patients with chronic HCV genotype 1 infection who have not been previously treated with sofosbuvir or an NS5A inhibitor give ledipasvir-sofosbuvir, sofosbuvir-velpatasvir, or glecaprevir-pibrentasvir (12-16).

·         For patients with advanced systemic mastocytosis give midostaurin for initial systemic therapy rather than imatinib or other cytoreductive therapies (17, 18).

·         In patients with a presumptive diagnosis of acquired TTP administer rituximab as a component of initial therapy (19).

·         For patients with cutaneous melanoma and a positive sentinel lymph node biopsy go for clinical observation and ultrasound surveillance of the positive nodal basin rather than immediate completion lymph node dissection [20].

·         For patients with newly diagnosed ALK-positive NSCLC go for alectinib as first-line treatment.  For those without access to alectinib, appropriate alternatives include crizotinib or ceritinib. For patients with advanced anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC), crizotinib has been administered as frontline therapy. However, newer agents have shown promising efficacy in advanced ALK-positive NSCLC (22,23).

·         For patients with an asymptomatic solid or subsolid (pure ground glass or part-solid) solitary pulmonary nodule (SPN) <6 mm, no routine follow-up is required. For patients with solid SPNs that have been stable on serial CT over a two-year period, or with subsolid SPNs that have been stable over a five-year period, we suggest no further diagnostic testing (24).

·         For women with postpartum hemorrhage diagnosed within three hours of delivery administer tranexamic acid as a component of overall treatment (25).

·         For patients with ALS who have a disease duration of two years or less, are living independently, and have an FVC ≥80 percent treat with edaravone and edaravone for patients with more advanced ALS (26,27).

·         For adults with acquired severe aplastic anemia who are not candidates for allogeneic hematopoietic cell transplantation treat with eltrombopag plus standard immunosuppressive therapy (IST) rather than IST alone (28).

·         For patients with primary progressive multiple sclerosis treat with ocrelizumab (29).

·         Scalp hypothermia can prevent chemotherapy-induced alopecia in women with breast cancer (30,31).

·         Do not give venom immunotherapy (VIT) to patients with reactions to stinging insects limited to cutaneous systemic symptoms and not involving other organ systems. However, VIT is effective in reducing the severity of future reactions and may still be offered in selected situations (32).

·         For most patients with chronic HBV infection who initiate therapy with tenofovir give tenofovir alafenamide rather than tenofovir disoproxil fumarate (tenofovir DF). Those initially started on tenofovir DF switch to tenofovir alafenamide (33-35).

References

1.     http://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/ (Accessed on October 19, 2017).

2.     7th International Workshop on HIV and Women. Seattle, WA. February 11-12, 2017.

3.     N Engl J Med 2017.

4.     Lancet Haematol 2017; 4:e524.

5.     Am J Gastroenterol 2017; 112:988.

6.     Blood Cancer J 2017; 7:e599.

7.     N Engl J Med 2017; 377:1022.

8.     N Engl J Med 2017; 377:1033.

9.     N Engl J Med 2017; 377:1011.

10.  Eur J Cancer 2017; 70:87.

11.  JAMA 2017; 318:132.

12.  52nd Annual Meeting of the European Association for the Study of the Liver (EASL), Amsterdam, The Netherlands, April 19-23, 2017.

13.  Lancet Infect Dis 2017; 17:1062.

14.  American Association for the Study of Liver Diseases Liver Meeting, Boston, MA, November 11-15, 2016.

15.  N Engl J Med 2017; 377:1448.

16.  N Engl J Med 2017; 376:2134.

17.  Leukemia 2017.

18.  N Engl J Med 2016; 374:2605.

19.  Blood Advances 2017; 1:1159.

20.  N Engl J Med 2017; 376:2211.

21.  N Engl J Med 2017; 377:829.

22.  Lancet 2017; 390:29.

23.  WCLC 2016; PL03.07.

24.  Radiology 2017; 284:228.

25.  Lancet 2017.

26.  Lancet Neurol 2017; 16:505.

27.  www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm557102.htm (Accessed on May 09, 2017).

28.  N Engl J Med 2017; 376:1540.

29.  N Engl J Med 2017; 376:209.

30.  JAMA 2017; 317:596.

31.  JAMA 2017; 317:606.

32.  Ann Allergy Asthma Immunol 2017; 118:28.

33.  www.gilead.com/news/press-releases/2016/11/us-food-and-drug-administration-approves-gileads-vemlidy-tenofovir-alafenamide-for-the-treatment-of-chronic-hepatitis-b-virus-infection

34.  Lancet Gastroenterol Hepatol 2016; 1:185.

35.  Lancet Gastroenterol Hepatol 2016; 1:196.

(Source: Uptodate)