In episode 118, James and Mike continue their discussion of atrial fibrillation by going into details about the evidence for treating patients with atrial fibrillation and how to make decisions between ASA/warfarin/dabigatran and also what it means to be in or out of the INR therapeutic range. At the end James gives Mike a well deserved, but late, Christmas present, and both their hearts skip a beat – but not enough to require anticoagulation.

Show notes

1) Canadian Cardiovascular Society 2010 Atrial Fibrillation Guidelines

2) Warfarin vs ASA in afib

Ann Intern Med 2007;146:857-67

Heart 2008;94:1607-1613

2) Time in therapeutic range

Can Fam Phys 2005; 51:384-5

Can Fam Phys 2003; 49:181-4

Family Practice 2004; 21:612–6

J Manag Care Pharm 2009:15:244-52

3) Event rates by INR range

CMAJ 2008;179(3):235-44

4) Clopidogrel and ASA in atrial fibrillation 

Lancet 2006;367:1903-12

NEJM 2009;360:2066-78  

NEJM 2009;360:2127-9

In episode 117, Mike and James delve into the first of a few podcasts on options for atrial fibrillation. In this first podcast they look at ways to assess risks and talk at length about a web-based tool that makes the process as easy as possible. The process is so easy that the hearts of both Mike and James start to flutter yet only one of them decides to take warfarin. You decide whom that is.

Show notes

1) Risk calculators for atrial fibrillation

The best/easiest way to present information about the risks associated with atrial fibrillation and the benefits and harms of therapy – from peterloewen.com

SPARC – Stroke Prevention in Atrial Fibrillation Risk Calculator

Other Afib calculators

md+calc

QxMD

2) Some useful Afib numbers

In episode 116, James and Mike take a re-look, with some new evidence, at the use of antibiotics for acute otitis media in children and come to the conclusion that antibiotics do have an effect and produce side effects. They both agree that if the child is really sick you may as well give antibiotics and if they aren’t really sick then you can wait. At the end of the podcast Mike agrees that this information doesn’t in anyway change what he already was doing. But at least he is now supported by 2 articles in the New England Journal of Medicine – which makes everything feel so much better.

Show notes

1) Two new otitis media trials

N Engl J Med 2011;364:116-26

N Engl J Med 2011;364:105-15

2) Systematic review of otitis media treatment

JAMA 2010;304:2161-9

In episode 115, Mike and James, in yet another stellar PREMIUM performance, provide the listening audience with the definitive answer on the cardiovascular risks associated with the NSAIDs. They then bring in a guest (Winnie-the-Pooh) to discuss in a sweet fashion whether or not there are any benefits from using honey for cough in children. At the end we are unable to recommend or not recommend honey, and so uncharacteristically Winnie-the Pooh bites both James and Mike and they end up on NSAIDs for the pain. 

Show notes

1) Cardiovascular safety of NSAIDs – or lack thereof

BMJ 2011; 342:c7086 doi: 10.1136/bmj.c7086

2) Acetaminophen/paracetamol

Causes liver damage and is “bad”

BMJ 2010; 341:c6764 doi: 10.1136/bmj.c6764

Hang-on, is it really bad or is it really safe? – and just how do you define narrow therapeutic ratio?

BMJ 2011; 2011; 342:d625 doi: 10.1136/bmj.d625 

“Other than citing a narrow therapeutic index, defined by the FDA as exceeding the daily 4,000 mg recommended maximum dose, between the therapeutic and toxic doses of acetaminophen, the FDA did not present any evidence upon which to validate their recommendation to reduce the daily dose from 4,000 to 3,250 mg”

Clin Toxicol 2009;47:784-9

2) Honey and cough in children 

J Alt Compl  Med 2010;16:787-93

In episode 114, James and Mike finally bring some topical information to the TEC podcast listeners by reviewing the available evidence for topical NSAIDs. We find out that they do work and that they should be considered a useful tool in your “how should I treat pain” armamentarium. Mike and James at the end of the podcast make a resolution to send all our PREMIUM podcast subscribers – if you aren’t one yet get on with it – a vat of a generic topical NSAID to help them with the intermittent pain associated with listening to the podcasts.

Show notes 

1) Tools for Practice – Topical NSAIDs: Do they top Placebo or Oral NSAIDs?

2) Evidence for topical NSAIDs

Cochrane Library Review – CD007402

BMJ 2004;329:324.doi:10.1136/bmj.38159.639028.7C 

BMC Musculoskeletal Disorders 2004 5:28 doi:10.1186/1471-2474-5-28.

J Rheumatol 2006;33:1841–4

Bandolier, 2003 April

Pain Medicine 2010;11:535–49

BMJ 2008;336:502-3. doi:10.1136/bmj.39490.608009.

NICE OA Guideline

In episode 113, Mike and James interact in a mainly positive way about what to do with the 1000s of drug interactions that are out there. They talk about the concepts of pharmacokinetic and pharmacodynamic interactions and outline which ones appear to be clinically important. At the end they realise that all of their interactions over the last 113 podcasts episodes have been clinically irrelevant and vow to interact much more usefully in the future.

Show notes

1) Hospitalizations due to interactions

BMJ 2004;329:15–19

2) Plasma-protein binding interactions – they are not clinically important

Br J Clin Pharmacol 1994;37:125-8

3) Key Players in Metabolism Drug Interactions

Inhibitors

fluvoxamine

gemfibrozil

fluconazole

omeprazole

paroxetine

fluoxetine

clarithromycin

Inducers

Rifampin

carbamazepine

4) What drug interactions are clinically important?

J Am Pharm Assoc 2004;44:142–151

THE MAIN ONES (DRUG affected – DRUG interacting)

Warfarin – Thyroid, NSAIDs, cimetidine, fibric acid, barbiturates, sulfinpyrazone

Benzodiazepines – Azoles

Carbamazepine – Propoxyphene, macrolides

Cyclosporine  – Rifampin

Dextromethorphan – MAOIs

Digoxin – Clarithromycin

Ergots  – Macrolides

Ganciclovir – Zidovudine

MAOIs – Sympathomimetics

Meperidine – MAOIs

Methotrexate – Trimethoprim

Nitrates – Sildenafil

Pimozide – Macrolides, azoles

SSRIs  – MAOIs

Theophylline – Quinolones, fluvoxamine

5) Oral contraceptives and antibiotic interactions – a myth?

J Am Acad Dermatol 2002;46:917-23

6) Drug interaction websites/tools

http://www.drugs.com/drug_interactions.php

http://www.rxfiles.ca/rxfiles/uploads/documents/members/cht-herbal-di.pdf

iPhone apps – Medscape, Epocrates

In episode 112, Mike and James discuss the who, what, why, where and when of dabigatran in atrial fibrillation. We look at the data, and then discuss what we as individuals would do when making a decision between dabigatran and warfarin. At the end we both agree to disagree with the fact that we agree to disagree.

Show notes

1) Dabigatran versus Warfarin in Patients with Atrial Fibrillation

N Engl J Med 2009;361:1139-51

N Engl J Med 2010;363:1875-76 – update

N Engl J Med 2009;361:1200-02 – editorial

2) Keeping INR in the range – does it make a difference when comparing warfarin to dabigatran

Lancet 2010;376:975–83

3) Tools For Practice – Dabigatran versus Warfarin in Atrial Fibrillation

James and Mike briefly outline the new PREMIUM TEC podcast model.

In episode 111, Mike and James bring you the premier edition of the new PREMIUM TEC podcast episodes. We discuss high dose versus low dose statins, we possibly put the final nail in the rosiglitazone coffin and finally report that single high annual doses of Vitamin D didn’t do what they were supposed to do. At the end we discuss whether or not the PREMIUM label really should have been given to this podcast and decide to let the listeners make that decision.

Show notes

1) SEARCH – low dose (20 mg) vs high dose (80 mg) simvastatin in patients after an MI

Lancet 2010;376:1658-69

2) Rosiglitazone – are we really done with it?

N Engl J Med 2007;356:2457-71

ACP Journal Club 2007Nov-Dec;147:66

Arch Intern Med 2010;170(14):1191-1201

Food and Drug Administration. Briefing document:July13-14,2010 meeting of the

Endocrinologic and Metabolic Drugs Advisory Committee

JAMA 2010;304:411-418

BMJ 2010;340:c1344.doi:10.1136/bmj.c1344

Diabetes Care 2009;32:193-203

3) Annual high-dose (500,000 IU) oral Vitamin D and falls and fractures in older women

JAMA 2010;303:1815-22

In episode 110, in this final episode of the year James and Mike attempt to answer even more questions. They discuss the benefits and harms of using atypical antipsychotics in the elderly and decide that ‘microdoses’ is the correct answer. They get into a heated debate on the issue of the interaction with PPIs and clopidogrel and at the end both agree on the answer which is “Yes, but only on a Tuesday”. We finish off with a rousing discussion on the grapefruit/felodipine interaction and realise that neither of us like grapefruit so who cares. We both wish you and your family a Happy Holidays.

Show notes

1) Data on benefit

Psychother Psychosom 2007;76:213-8

Cochrane Library 2006:CD003476

2) Data on harm

Atypical meta-analysis (of trials not designed to assess harm)

JAMA 2005;294:1934-43

Cohort of conventional vs atypical

NEJM 2005;353:2335-41

CMAJ 2007;176:627-32

3) Actual RCT to assess risk benefit of withdrawal of antipsychotics

Lancet Neurol 2009;8:151–57

PLoS Med 5(4): e76.doi:10.1371/journal.pmed.0050076

4) One page summary of risks/benefits of anti-psychotics:

See Tools for Practice Website: http://www.acfp.ca/tfp_original.php

Specific reference: http://www.acfp.ca/docs10/Antipsychotics%20in%20Elderly%20_2_.pdf