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

In episode 109, Mike and James continue on with listener questions and start off trying to reduce the risk of using risk assessment tools and risk reduction information. They then delve into questions about tapering steroids, antidepressants, side effects from thiazides and sitagliptin and the amazing clarity of their answers is only outdone by the vagueness of their conclusions.

Show notes

1) Prediction with Framingham versus the real risk primary care patients

Heart 2009;95:125–9

2) Relative risk reduction with statins in primary prevention

BMJ 2009;338:b2376

ACP J Club 2009;151:14

Lancet 2005;366:1267–78

Diabetes – Lancet 2008;371:117–25

3) Issues with Framingham/UKPDS risk assessments

4) Tapering corticosteroids

Am J Med 2009;1222:977-91

5) Incomplete publication of antidepressant studies leading to bias (publication bias)

NEJM 2008;358:252-60

BMJ 2003;326:1171-3

6) Meta-analysis of antidepressants

Ann Intern Med 2005;143:415-26

Ann Intern Med 2008;149:734-50

Lancet 2009;373:746–58

Tools for Practice Website

http://www.acfp.ca/docs09/SecondGenerationAntidepressantsToolsforPracticefinal.pdf

In episode 108, Mike and James get back to listener questions and discuss drugs in the same class and different classes, get nowhere on a discussion about how to extrapolate 5-year data to infinity and beyond, get a little smelly with fish oil data, and find out that the new low dose colchicine is also high price which also stinks. Finally we sort out a steroid and sore throat issue and at the end both James and Mike find all their answers difficult to swallow.

Show notes

1) Fish oil

Arch Intern Med 2005;165:725-30

Can Fam Phys 2006;52:734-40

BMJ 2006;332:752-760

2) Colchicine – exclusive rights and high costs

N Engl J Med 2010;362:2045-7

3) Sore throat and steroids

www.emergency-medicine.jwatch.org/cgi/content/full/2009/828/1

In episode 107, Mike, James and Bruce Arroll once again team-up and this time bring you a cornucopia of dermatolgical evidence and advice. By the end of the podcast, both Mike and James develop psychogenic itch and Bruce successfully treats them with Kenacomb.

Show notes

1) DermNet NZ – pictures of more rashes than you could possibly imagine

http://dermnet.org.nz

2) Erythromycin for Pityriasis rosea

J Am Acad Dermatol 2000;42:241-4

3) Community-acquired pneumonia – covering for the atypicals – is it really needed?

BMJ 2005;330:456 doi:10.1136/bmj.38334.591586.82

4) Chronic erythromcin for COPD

Am J Respir Crit Care Med 2008;178:1139-47

5) TMP/SMX for head lice

Pediatrics 2001;107:e30

6) Send in pictures of your rashes and find out what it is

http://www.telederm.org/

7) Recurrent eczema – liquid bleach

Pediatrics 2009;123:e 808-14

In episode 106, James and Mike welcome back our good friend and colleague from New Zealand, Bruce Arroll. Out of respect, we made sure there were no earthquakes during his visit because earthquakes, as we found out, can be somewhat depressing. On that note, Bruce brings us some very useful information about non-drug treatments for depression and towards the end Mike and James breath deeply, meditate, problem solve and then write about it in their gratitude diaries and lo-and-behold we finish the podcast feeling much better than when we started – always a good thing.

Show notes

Seeing patients weekly

BMJ 2001;323:1011

Exercise

Cochrane Library

Practice nurse phone call

Arch Fam Med 2000;9:700-8

Gratitude diaries

Am Psychologist 2005;60:5:410–421

Breathing

Int J Nurs Stud 2010;47:1346–1353

Meditation

www.calm.auckland.ac.nz

J Consult Clin Psychol 2008;76:966-78

Light therapy

Cochrane Library

Problem solving

BMJ 1995;310:441-5

Cognitive behavioural therapy

10 Minute Consultation By Lee David

J Affect Disord 1998;49:59-72

In episode 105, James and Mike continue on with breathless abandon their discussion about the use of drugs in asthma. With chronic asthma the whole concept of low dose and shared-informed decision making comes right back into focus (thank goodness) and so both of us rest easy that the last 104 podcasts, at least from that perspective, have not been a waste of time.

Show notes

1) PRN versus chronic use of inhaled salbutamol

Lancet 2000;355:1675-9

2) Inhaled corticosteroids in patients with new-onset asthma

NEJM 1991;325:388-92

“all patients with mild persistent asthma deserve the opportunity to decide whether the benefit from their use is worth the effort of taking a very safe medication,  usually once daily”

Am J Res Crit Care Med 2005;172:410-2

3) Choice of inhaled corticosteroid – no difference

Ann Allergy Asthma Immunol 2003;91:326-34

Ann Pharmaco 2009;43:519-27

4) Doses of inhaled corticosteroid – low doses

“published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma”

Cochrane Library

5) Equipotent daily doses of inhaled corticosteroids in adults – the doses listed below are considered ‘low” doses, “moderate doses = doubling these doses; “high” doses = quadrupling these doses. In children the corresponding doses are usually about 2/3 of the adult doses

Triamcinolone/Flunisolide 400/500-1000 mcg

Beclomethasone 200-500 mcg

Budesonide /Mometasone 200-400 mcg

Fluticasone 100-250 mcg

Ciclesonide 80-160 mcg

Eur Respir J 2008;31:143–78

6) Doubling the dose of inhaled CS when symptoms get worse provides no benefit

Lancet 2004;363:271-5

Thorax 2004;59:550–6

Cochrane Library

7) Maybe quadrupling the dose will work????

Am J Respir Crit Care Med 2009;180:598–602

8) High dose inhaled corticosteroids can often be reduced without any change  in symptom control

NEJM 1994;331:700-5

9) After inhaled steroids what’s next – tiotropium or salmeterol?

NEJM 2010;Sept 19

10) LABA vs LTRA

“In asthmatic adults inadequately controlled on low doses of inhaled steroids, the addition of LABA is superior to LTRA for preventing exacerbations requiring systemic steroids, and for improving lung function, symptoms, and use of rescue ß2-agonists”

Cochrane Library

11) Peak flow measurements

Am J Respir Crit Care Med 2006;174:1077–87

In episode 104, Mike and James blow out a lot of hot air about the use of medications for acute asthma and they come to the quick realization that the concepts they have been evangelising for the past 2 years (low dose and shared-informed decision making) have no role in acute asthma. James, in an act of defiance gets a cat to sit on top of Mike’s head until becomes acutely short of breath and then gives Mike a 1/4 puff of salbutamol. Shockingly, the outcome was less than optimal.

Show notes

1) Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma

Cochrane review

2) Continuous versus intermittent beta-agonists for acute asthma

Cochrane review

3) Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children

Cochrane review

4) Early emergency department treatment of acute asthma with systemic corticosteroids

Cochrane review

5) Magnesium for acute asthma

Cochrane review

6) Aminophylline for acute asthma

Cochrane review

In episode 103, James and Mike discuss the whole concept of discussion of side effects with patients. They rarely disagree but commonly get confused and at the end they both develop all the side effects discussed, which goes completely against the available literature.

Show notes

1) Important elements of outpatient care

Ann Intern Med 1996;125:640-5

2) The consent form that caused side effects

Clin Pharmacol Ther 1987;42:250-3

3) The evidence that telling patients about side effects doesn’t cause side effects

Br J Psych 1973;122:461-4

Br J Psych 1978;132:526-7

J Behav Med 1982;5:263-73

Br J Clin Pharmac 1984;17:21-5

Br J Clin Pharmac 1989;27:723-39

J Fam Pract 1990;31:62-4

Arch Int Med 1994;154:2753-6

4) If you are allergic you are allergic

N Engl J Med 2003;349:1628-35

5) Why you shouldn’t use words to describe the magnitude of side effects

Lancet 2002;359:853–54

In episode 102, Mike and James, with laser precision, look at the evidence around blood pressure targets. We cover data in non-diabetics, diabetics, chronic kidney disease and the elderly. At the end they agree that the BP target we used 30 years ago (140/90) is still pretty good. To prove the point James gives Mike some sublingual nifedipine and Mike demonstrates the J-curve by falling on the floor and ‘pretending’ to be unable to get up (faker!).

Show notes
1) Systematic review of intensive BP treatment

Cochrane review CD004349

2) ACCORD blood pressure study
N Engl J Med 2010;362:1575-8

3) CARDIO-Sis
Lancet 2009;374:525–33

4) AASK – chronic kidney disease
N Engl J Med 2010;363:918-29

5) INVEST – retrospective data
JAMA 2010;304:61-68

6) BP guidelines
US
Curr Hypertens Rep 2010; 12:290–295
The Seventh Report of the Joint National Committee on: Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. August 2004
Canadian
2009 Canadian Hypertension Education Program Recommendations: The Scientific Summary
European
J Hypertension 2009, 27:2121–2158

7) BP in the elderly
N Engl J Med 2008;358:1887-98
Hypertens Res 2008;31:1595-601
Hypertension 2010;56:196-202

In episode 101, your friendly centurions, James and Mike, take a shot at the evidence around target doses for drugs in CHF and find the data is not as compelling as one might think. They discuss the approach of making sure we don’t cause side effects trying to get patients to these targets.  To prove the point, we both took high doses of ACE inhibitors, ARBs, and beta-blockers at the beginning of the podcast and the recording results clearly demonstrate the harm  that can occur from arbitrary use of high doses of medications.

Show notes

1) Getting to carvedilol doses

QJM 2004;97: 133-9

2) Network – ACE doses

Eur Heart J 1998;19:481-9

3) ATLAS – ACE doses

Circ 1999;100:2312-8

4) Carvedilol doses

Circulation 1996;94:2807-16

4) Beta-blocker doses

Ann Intern Med 2009;150:784-94

5) HEAAL – losartan

Lancet 2009;374;1840-8