Данный блог содержит резюме и ссылки на полные тексты зарубежных и российских клинических рекомендаций по самым широким областям внутренней медицины. Сайт предназначен для российских врачей, которые хотят лечить своих пациентов качественно и грамотно, согласно последним достижениям современной доказательной медицины.
Вся представленная здесь информация предназначена для ознакомления и некоммерческого использования.

четверг, 18 сентября 2008 г.

Клинические рекомендации ACP по лечению остеопороза

Рекомендации вкратце.
1. Выявленный остеопороз надо лечить, особенно при наличии переломов, связанных с ним, в анамнезе. Результаты исследований: для профилактики переломов позвонков - алендронат, ибандронат, ризедронат, кальцитонин, терипаратид, ралоксифен; как переломов позвонков, так и переломов бедра (и другой локализации) - ризедронат, алендронат, терипаратид, эстрогены. Кальцин+витамин D - только как дополнение к одному из перечисленных препаратов. Длительность лечения неопределённая.
2. Лечить надо и тех, у кого есть факторы риска остеопороза, а показатели денситометрии составляют от -1,5 до -2,5 и менее. Факторы рика у мужчин: возраст более 70, низкая масса тела (ИМТ <25), потеря веса >10%, небольшая физическая активность, приём кортикостероидов, терапия антиандрогенами. Факторы риска у женщин: низкая масса тела, курение, потеря веса, семейный анамнез, низкая физическая активность, повышенное употребление алкоголя или кофеина, недостаточное поступление кальция и витамина D. Калькулятор ВОЗ для определения риска развития переломов.
3. Выбор препаратов должен быть индивидуализированным. Препараты первой линии обычно бисфосфонаты (из них наиболее изучены алендронат и ризедронат, побочные эффекты - расстройства ЖКТ). Препараты второй линии - эстрогены (побочные эффекты - инсульт), вспомогательные - кальций и витамин D.
4. Нужны исследования у мужчин, а также проспективные - относительно необходимой длительности лечения.
Полностью текст бесплатно - здесь. Файл pdf.

воскресенье, 7 сентября 2008 г.

Лечение ВИЧ 2008

Краткое изложение
# Treatment should be started before CD4 cell count decreases to less than 350/μL, based on review of new data and considerations.
# Deciding whether to start treatment in patients with a CD4 cell count of 350 cells/μL or more should be individualized based on the presence of comorbidities, risk factors for progression to AIDS and non-AIDS diseases, and patient willingness to begin treatment.
# As noted in previous guidelines, factors prompting treatment initiation are a high plasma viral load (>100,000 copies/mL) and rapidly decreasing CD4 cell count (>100/μL per year).
# Newly recognized factors prompting earlier treatment initiation are active hepatitis B or C virus coinfection, cardiovascular disease risk, and HIV-associated nephropathy.
# The initial regimen must be individualized, particularly when there are comorbid conditions.
# The initial treatment regimen typically includes efavirenz or a ritonavir-boosted PI plus 2 NRTIs (tenofovir/emtricitabine or abacavir/lamivudine).
# Treatment failure should be promptly identified and managed.
# Even in heavily pretreated patients, the goal of treatment is an HIV-1 RNA level below assay detection limits.
* The initial treatment regimen for HIV infection must be individualized, particularly in patients with comorbid conditions, but typically includes efavirenz or a ritonavir-boosted PI plus 2 NRTIs (tenofovir/emtricitabine or abacavir/lamivudine). Even in heavily pretreated patients, the goal of treatment is an HIV-1 RNA level below assay detection limits. Treatment failure should be promptly identified and managed.
* Treatment should be started before CD4 cell count decreases to less than 350/μL. Factors prompting treatment initiation are a high plasma viral load (>100,000 copies/mL), rapidly decreasing CD4 cell count (>100/μL per year), active hepatitis B or C virus coinfection, cardiovascular disease risk, and HIV-associated nephropathy.
Скачать полный текст (JAMA)
Discover Simple, Private Sharing at Drop.io

Лечение аллергического ринита 2008

Совместные клинические рекомендации обществ американских иммунологов и аллергологов по лечению аллергического ринита.
* When used continuously, oral antihistamines, or oral H1-receptor antagonists, are most effective for seasonal AR and perennial AR, but their relatively rapid onset of action also makes them appropriate for as-needed use in episodic AR.
* Oral antihistamines are less effective for nasal congestion vs other nasal symptoms, and other options are generally preferred for more severe AR. For AR, oral antihistamines are less effective for AR vs INS, but they are similarly effective to INS for associated ocular symptoms.
* Oral antihistamines are typically ineffective for non-AR, resulting in other choices being better for mixed rhinitis.
* Second-generation oral antihistamines are usually preferred over first-generation antihistamines to minimize sedation, performance impairment, and anticholinergic effects. At recommended doses, the second-generation oral antihistamines fexofenadine, loratadine, and desloratadine do not cause sedation.
* Oral corticosteroids may be appropriate for very severe nasal symptoms when given as a short course (5 - 7 days) and are preferred to single or repeated administration of intramuscular corticosteroids, which should be discouraged.
* Oral decongestants include pseudoephedrine, which reduces nasal congestion, although adverse effects include insomnia, irritability, palpitations, and hypertension.
* Of the LTRA, montelukast is approved for seasonal AR and perennial AR, and adverse effects are minimal. However, with loratadine as the usual comparator, LTRA have not been shown to have significantly different efficacy from oral antihistamines. Because LTRA are approved for both rhinitis and asthma, they may be considered in patients who have both conditions.
* Intranasal antihistamines are effective for both seasonal AR and perennial AR. Their clinically significant, rapid onset of action also makes them suitable for as-needed use in episodic AR. Although their efficacy for AR is as good as or better than oral second-generation antihistamines, with a clinically significant effect on nasal congestion, they are not as effective as INS for nasal symptoms. Because they are also approved for vasomotor rhinitis, they are a suitable option for patients with mixed rhinitis. The adverse effects of intranasal azelastine are a bitter taste and somnolence.
* Intranasal anticholinergic (ipratropium) has a rapid onset of action and is therefore appropriate for episodic rhinitis. Although it reduces rhinorrhea, it is ineffective for other symptoms of seasonal AR and perennial AR. There may be dryness of nasal membranes, but adverse effects are otherwise minimal.
* INS are the most effective monotherapy for seasonal AR and perennial AR because of their efficacy for all symptoms of seasonal AR and perennial AR, including nasal congestion. As-needed use of INS may be effective for seasonal AR and may also be considered in patients with episodic AR. The typical onset of action is within 12 hours, which is less rapid than with oral or intranasal antihistamines, but symptom relief may begin within 3 to 4 hours in some patients.
* For seasonal AR and perennial AR, INS are more effective than combination therapy with oral antihistamine and LTRA. For associated ocular symptoms of AR, efficacy of INS is similar to that of oral antihistamines. INS are also a suitable option for mixed rhinitis, because agents in this class are also effective for some non-AR. INS do not have significant systemic adverse effects in adults, and when used at recommended doses, they have not been shown to cause growth suppression in children with perennial AR. Local adverse effects are minimal, but nasal irritation and bleeding occur, and nasal septal perforation has rarely been reported.
* Intranasal cromolyn may be useful for maintenance treatment of AR. The onset of action is within 4 to 7 days, but the full benefit may not be evident for weeks. Administration just before allergen exposure for episodic rhinitis protects against the allergic response for 4 to 8 hours. Intranasal cromolyn is not as effective as INS, and data are insufficient to compare INS with LTRA and antihistamines.

Скачать бесплатно здесь

суббота, 6 сентября 2008 г.

Невралгия тройничного нерва

Новые рекомендации Американской академии неврологии будут опубликованы в номере от 7 октября 2008 года журнала Neurology.
TN is a common cause of facial pain, the authors write, with an annual incidence of 4 to 5 in 100,000. The International Association for the Study of Pain defines TN as sudden, usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of the trigeminal nerve.
* For patients with TN, routine imaging should be done to identify those patients with symptomatic TN (STN) — that is, TN arising from some other structural abnormality (level C).
* The presence of trigeminal sensory deficits should be considered useful to identify those with STN, they note, but because of poor specificity, the absence of these features cannot rule out STN (level B).
* Measuring trigeminal reflexes in a qualified electrophysiologic laboratory should be considered useful for distinguishing STN from classic TN (CTN), a designation that includes all cases without an established etiology (level B).
* Younger age at onset, involvement of the first division of the trigeminal nerve, unresponsiveness to treatment, and abnormal trigeminal-evoked potentials should be disregarded in identifying those with STN (level B).
* To control pain in TN, carbamazepine should be offered (level A), and oxcarbazepine should be considered (level B). Although the evidence for carbamazepine is stronger, they note, oxcarbazepine may pose fewer safety concerns. Baclofen or lamotrigine may be considered (level C). Topical ophthalmic anesthesia should not be considered (level B).
* For patients refractory to medical therapy, early surgical therapy may be considered (level C), they note. "Some TN experts believe patients with TN failing to respond to first-line therapy are unlikely to respond to alternative medications and suggest early surgical referral," the authors write. Percutaneous procedures on the Gasserian ganglion, gamma knife, and microvascular decompression may be considered (level C).
Полный текст здесь

Ведение женщин в постменопаузе

"In the United States, the median age at which menopause occurs is 52 years, but it can vary between 40 and 58 years of age," write Shobha S. Rao, MD, from the University of Texas Southwestern Medical Center in Dallas, and colleagues. "The World Health Organization (WHO) and the Stages of Reproductive Aging Workshop have defined menopausal transition as the time of an increase in follicle-stimulating hormone and either increased variability in menstrual cycle length, two skipped menstrual cycles with 60 days or more of amenorrhea, or both. It concludes with the final menstrual period, [and] postmenopause begins at that time, although it is not recognized until after 12 months of amenorrhea."
These recommendations, and their accompanying level of evidence rating, are as follows:

* In women who are aware of the risks and benefits and who are under medical supervision, extended use of hormone therapy is acceptable for those who believe that the benefits of menopausal symptom relief outweigh the risks, for those with moderate to severe menopausal symptoms and who are at high risk for osteoporotic fractures, and for those with decreased bone mass who wish to prevent additional bone loss when alternate therapies are contraindicated or otherwise inappropriate (level of evidence, C).
* To maintain bone health, all postmenopausal women should consume adequate amounts of calcium (1000 - 1500 mg of elemental calcium per day) and vitamin D (800 - 1000 IU per day) (level of evidence, C).
* For women at high risk for coronary heart disease, aspirin chemoprophylaxis is recommended (level of evidence, A).
* Beginning at age 40 years, women should be screened for breast cancer every 1 to 2 years (level of evidence, B).
* Women who are or who have been sexually active and who have a cervix should be routinely screened for cervical cancer (level of evidence, A).
* Beginning at age 50 years, women should be screened for colorectal cancer (level of evidence, A).
Источник - Am Fam Physician. 2008;78:583-591 Полный текст.

Диагностика и лечение первичного альдостеронизма

В сентябрьском номере Journal of Clinical Endocrinology & Metabolism опубликованы новые клинические рекомендации по диагностике и лечению первичного альдостеронизма.
PA is a group of disorders in which aldosterone production is inappropriately high, relatively autonomous from the renin-angiotensin system, and nonsuppressible by sodium loading. Such inappropriate production of aldosterone causes cardiovascular damage, suppression of plasma renin, hypertension, sodium retention, and potassium excretion that if prolonged and severe may lead to hypokalemia. PA is commonly caused by an adrenal adenoma, by unilateral or bilateral adrenal hyperplasia, or in rare cases by the inherited condition of glucocorticoid-remediable aldosteronism (GRA).
Specific guidelines regarding diagnosis of PA are as follows:

* Case detection of PA is recommended in patient groups with relatively high prevalence of PA, including patients with Joint National Commission stage I (> 160 - 179/100 - 109 mm Hg), stage II (> 180/110 mm Hg), or drug-resistant hypertension; hypertension and spontaneous or diuretic induced hypokalemia; hypertension with adrenal incidentaloma; or hypertension and a family history of early-onset hypertension or cerebrovascular accident at age younger than 40 years. Case detection is also recommended for all hypertensive first-degree relatives of patients with PA.
* To detect cases of PA in the patient groups just mentioned, use of the plasma aldosterone-renin ratio (ARR) is recommended.
* To definitively confirm or rule out the diagnosis of PA, it is recommended that patients with a positive ARR undergo testing by any of 4 confirmatory tests instead of proceeding directly to subtype classification.
* As the initial study in subtype testing, an adrenal computed tomography scan is recommended in all patients with PA. This test also excludes large masses that may represent adrenocortical carcinoma.
* Adrenal venous sampling by an experienced radiologist is recommended to distinguish between unilateral and bilateral adrenal disease, when surgical treatment is feasible, and the patient is willing to undergo the procedure.
* Genetic testing for GRA is suggested in patients in whom confirmed PA begins before 20 years of age and in those with a family history of PA or strokes at 40 years of age or younger.

Specific guidelines regarding treatment of PA are as follows:

* For patients with documented unilateral PA, treatment by unilateral laparoscopic adrenalectomy is recommended. Medical treatment with a mineralocorticoid receptor antagonist is recommended for patients who cannot or who do not wish to undergo surgery.
* Medical treatment with a mineralocorticoid receptor antagonist is recommended for patients with PA caused by bilateral adrenal disease. Spironolactone is suggested as the primary agent, with eplerenone as an alternative.
* Use of the lowest dose of glucocorticoid that can normalize blood pressure and serum potassium levels is recommended in patients with GRA, rather than first-line treatment with a mineralocorticoid receptor antagonist.
Скачать полный текст (для ознакомления)