Primary Care/Internal Medicine

Alternating-air and low-air-loss mattresses and overlays have little data to support their use for preventing or treating pressure ulcers, the Clinical Guidelines Committee of the American College of Physicians has concluded.

Many U.S. acute-care hospitals, home caregivers, and long-term nursing facilities use alternating-air and low-air-loss mattresses and overlays, even though the evidence in favor of using these surfaces is sparse and of poor quality, the guideline writers said.

The devices have not been show to actually reduce pressure ulcers. The harms have been poorly reported but could be significant. “Using these support systems is expensive and adds unnecessary burden on the health care system. Based on a review of the current evidence, lower-cost support surfaces should be the preferred approach to care,” Dr. Amir Qaseem, of the ACP, Philadelphia, and his associates wrote.

The committee performed an extensive review of the literature on pressure ulcers and compiled two Clinical Practice Guidelines – one concerning prevention (Ann. Intern. Med. 2015;162 [doi:10.7326/M14-1567]) and the other concerning treatment (Ann. Intern. Med. 2015;162 [doi:10.7326/M14-1568]) – in part because “a growing industry” has developed in recent years and aggressively pitches a wide array of products for this patient population. The guidelines present the available evidence on the comparative effectiveness of tools and strategies but state repeatedly that evidence regarding pressure ulcers is sparse and of poor quality.

The prevention guideline strongly recommends that clinicians choose advanced static mattresses or advanced static overlays rather than standard hospital mattresses for at-risk patients. Static mattresses and advanced static overlays provide a constant level of inflation or support and evenly distribute body weight. These products are among the few actually shown to reduce the incidence of pressure ulcers. They are also preferable to alternating-air mattresses and overlays, which change the distribution of pressure by inflating or deflating cells within the devices, and to low-air-loss mattresses and overlays, which use flowing air to regulate heat and humidity and adjust pressure.

Evidence is similarly poor or lacking concerning the use of other support surfaces such as heel supports or boots and a variety of wheelchair cushions. Also lacking evidence are other preventive interventions that extend beyond “usual care,” such as different types of repositioning schemes, a variety of leg elevations, various nutritional supplements, and a wide variety of skin care strategies and topical treatments.

The prevention guideline advises patient assessments to identify those at risk of developing pressure ulcers. However, there is not enough evidence to demonstrate that any one of the many risk assessment tools for this purpose is superior to the others, nor that any of these tools is superior to simple clinical judgment. Risk factors for pressure ulcers include older age; black race or Hispanic ethnicity; low body weight; cognitive impairment; physical impairments; and comorbid conditions that may affect soft-tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition, Dr. Qaseem and his associates wrote (Ann. Intern. Med. 2015 March 2 [doi:10.7326/M14-1567]).

The treatment guideline for patients who already have pressure ulcers similarly notes that the lack of evidence for advanced support surfaces such as alternating-air and low-air-loss mattresses and overlays. It similarly recommends advanced static mattresses or overlays for these patients.

The treatment guideline recommends protein or amino acid supplements as well as hydrocolloid or foam dressings to reduce wound size, and electrical stimulation to accelerate wound healing. The evidence for these recommendations is “weak” and of low- to moderate-quality, Dr. Qaseem and his associates said (Ann. Intern. Med. 2015 March 2 [doi:10.7326/M14-1568]).

The evidence for the safety and efficacy of hyperbaric oxygen therapy, even though it is often used to treat pressure ulcers in hospitals, is similarly inconclusive. Also lacking good-quality evidence are the use of alternating-air chair cushions, three-dimensional polyester overlays, zinc supplements, L-carnosine supplements, wound dressings other than the ones already discussed, debriding enzymes, topical phenytoin, maggot therapy, biological agents other than platelet-derived growth factor, or hydrotherapy in which wounds are cleaned using a whirlpool or pulsed lavage.

Alternating-air and low-air-loss mattresses and overlays have little data to support their use for preventing or treating pressure ulcers, the Clinical Guidelines Committee of the American College of Physicians has concluded.

Many U.S. acute-care hospitals, home caregivers, and long-term nursing facilities use alternating-air and low-air-loss mattresses and overlays, even though the evidence in favor of using these surfaces is sparse and of poor quality, the guideline writers said.

The devices have not been show to actually reduce pressure ulcers. The harms have been poorly reported but could be significant. “Using these support systems is expensive and adds unnecessary burden on the health care system. Based on a review of the current evidence, lower-cost support surfaces should be the preferred approach to care,” Dr. Amir Qaseem, of the ACP, Philadelphia, and his associates wrote.

The committee performed an extensive review of the literature on pressure ulcers and compiled two Clinical Practice Guidelines – one concerning prevention (Ann. Intern. Med. 2015;162 [doi:10.7326/M14-1567]) and the other concerning treatment (Ann. Intern. Med. 2015;162 [doi:10.7326/M14-1568]) – in part because “a growing industry” has developed in recent years and aggressively pitches a wide array of products for this patient population. The guidelines present the available evidence on the comparative effectiveness of tools and strategies but state repeatedly that evidence regarding pressure ulcers is sparse and of poor quality.

The prevention guideline strongly recommends that clinicians choose advanced static mattresses or advanced static overlays rather than standard hospital mattresses for at-risk patients. Static mattresses and advanced static overlays provide a constant level of inflation or support and evenly distribute body weight. These products are among the few actually shown to reduce the incidence of pressure ulcers. They are also preferable to alternating-air mattresses and overlays, which change the distribution of pressure by inflating or deflating cells within the devices, and to low-air-loss mattresses and overlays, which use flowing air to regulate heat and humidity and adjust pressure.

Evidence is similarly poor or lacking concerning the use of other support surfaces such as heel supports or boots and a variety of wheelchair cushions. Also lacking evidence are other preventive interventions that extend beyond “usual care,” such as different types of repositioning schemes, a variety of leg elevations, various nutritional supplements, and a wide variety of skin care strategies and topical treatments.

The prevention guideline advises patient assessments to identify those at risk of developing pressure ulcers. However, there is not enough evidence to demonstrate that any one of the many risk assessment tools for this purpose is superior to the others, nor that any of these tools is superior to simple clinical judgment. Risk factors for pressure ulcers include older age; black race or Hispanic ethnicity; low body weight; cognitive impairment; physical impairments; and comorbid conditions that may affect soft-tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition, Dr. Qaseem and his associates wrote (Ann. Intern. Med. 2015 March 2 [doi:10.7326/M14-1567]).

The treatment guideline for patients who already have pressure ulcers similarly notes that the lack of evidence for advanced support surfaces such as alternating-air and low-air-loss mattresses and overlays. It similarly recommends advanced static mattresses or overlays for these patients.

The treatment guideline recommends protein or amino acid supplements as well as hydrocolloid or foam dressings to reduce wound size, and electrical stimulation to accelerate wound healing. The evidence for these recommendations is “weak” and of low- to moderate-quality, Dr. Qaseem and his associates said (Ann. Intern. Med. 2015 March 2 [doi:10.7326/M14-1568]).

The evidence for the safety and efficacy of hyperbaric oxygen therapy, even though it is often used to treat pressure ulcers in hospitals, is similarly inconclusive. Also lacking good-quality evidence are the use of alternating-air chair cushions, three-dimensional polyester overlays, zinc supplements, L-carnosine supplements, wound dressings other than the ones already discussed, debriding enzymes, topical phenytoin, maggot therapy, biological agents other than platelet-derived growth factor, or hydrotherapy in which wounds are cleaned using a whirlpool or pulsed lavage.

Alternating-air and low-air-loss mattresses and overlays have little data to support their use for preventing or treating pressure ulcers, the Clinical Guidelines Committee of the American College of Physicians has concluded.

Many U.S. acute-care hospitals, home caregivers, and long-term nursing facilities use alternating-air and low-air-loss mattresses and overlays, even though the evidence in favor of using these surfaces is sparse and of poor quality, the guideline writers said.

The devices have not been show to actually reduce pressure ulcers. The harms have been poorly reported but could be significant. “Using these support systems is expensive and adds unnecessary burden on the health care system. Based on a review of the current evidence, lower-cost support surfaces should be the preferred approach to care,” Dr. Amir Qaseem, of the ACP, Philadelphia, and his associates wrote.

The committee performed an extensive review of the literature on pressure ulcers and compiled two Clinical Practice Guidelines – one concerning prevention (Ann. Intern. Med. 2015;162 [doi:10.7326/M14-1567]) and the other concerning treatment (Ann. Intern. Med. 2015;162 [doi:10.7326/M14-1568]) – in part because “a growing industry” has developed in recent years and aggressively pitches a wide array of products for this patient population. The guidelines present the available evidence on the comparative effectiveness of tools and strategies but state repeatedly that evidence regarding pressure ulcers is sparse and of poor quality.

The prevention guideline strongly recommends that clinicians choose advanced static mattresses or advanced static overlays rather than standard hospital mattresses for at-risk patients. Static mattresses and advanced static overlays provide a constant level of inflation or support and evenly distribute body weight. These products are among the few actually shown to reduce the incidence of pressure ulcers. They are also preferable to alternating-air mattresses and overlays, which change the distribution of pressure by inflating or deflating cells within the devices, and to low-air-loss mattresses and overlays, which use flowing air to regulate heat and humidity and adjust pressure.

Evidence is similarly poor or lacking concerning the use of other support surfaces such as heel supports or boots and a variety of wheelchair cushions. Also lacking evidence are other preventive interventions that extend beyond “usual care,” such as different types of repositioning schemes, a variety of leg elevations, various nutritional supplements, and a wide variety of skin care strategies and topical treatments.

The prevention guideline advises patient assessments to identify those at risk of developing pressure ulcers. However, there is not enough evidence to demonstrate that any one of the many risk assessment tools for this purpose is superior to the others, nor that any of these tools is superior to simple clinical judgment. Risk factors for pressure ulcers include older age; black race or Hispanic ethnicity; low body weight; cognitive impairment; physical impairments; and comorbid conditions that may affect soft-tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition, Dr. Qaseem and his associates wrote (Ann. Intern. Med. 2015 March 2 [doi:10.7326/M14-1567]).

The treatment guideline for patients who already have pressure ulcers similarly notes that the lack of evidence for advanced support surfaces such as alternating-air and low-air-loss mattresses and overlays. It similarly recommends advanced static mattresses or overlays for these patients.

The treatment guideline recommends protein or amino acid supplements as well as hydrocolloid or foam dressings to reduce wound size, and electrical stimulation to accelerate wound healing. The evidence for these recommendations is “weak” and of low- to moderate-quality, Dr. Qaseem and his associates said (Ann. Intern. Med. 2015 March 2 [doi:10.7326/M14-1568]).

The evidence for the safety and efficacy of hyperbaric oxygen therapy, even though it is often used to treat pressure ulcers in hospitals, is similarly inconclusive. Also lacking good-quality evidence are the use of alternating-air chair cushions, three-dimensional polyester overlays, zinc supplements, L-carnosine supplements, wound dressings other than the ones already discussed, debriding enzymes, topical phenytoin, maggot therapy, biological agents other than platelet-derived growth factor, or hydrotherapy in which wounds are cleaned using a whirlpool or pulsed lavage.

Persons exposed to smallpox should be vaccinated with a replication-competent vaccine, unless they are severely immunodeficient, according to a guideline from the Centers for Disease Control and Prevention.

© CDC

Severely immunodeficient persons won’t benefit from a smallpox vaccination because there will likely be a poor immune response and heightened risk of negative events. These include bone marrow transplant recipients within 4 months of transplantation, people infected with HIV with CD4 cell counts <50 cells/mm³, persons with severe combined immunodeficiency, complete DiGeorge syndrome patients, and people with other severely immunocompromised states requiring isolation.

“If antivirals are not immediately available, it is reasonable to consider the use of Imvamune in the setting of a smallpox virus exposure in persons with severe immunodeficiency,” the CDC added.

Find the full guideline in the MMWR (February 20, 2015 / 64(RR02);1-26).

Persons exposed to smallpox should be vaccinated with a replication-competent vaccine, unless they are severely immunodeficient, according to a guideline from the Centers for Disease Control and Prevention.

© CDC

Severely immunodeficient persons won’t benefit from a smallpox vaccination because there will likely be a poor immune response and heightened risk of negative events. These include bone marrow transplant recipients within 4 months of transplantation, people infected with HIV with CD4 cell counts <50 cells/mm³, persons with severe combined immunodeficiency, complete DiGeorge syndrome patients, and people with other severely immunocompromised states requiring isolation.

“If antivirals are not immediately available, it is reasonable to consider the use of Imvamune in the setting of a smallpox virus exposure in persons with severe immunodeficiency,” the CDC added.

Find the full guideline in the MMWR (February 20, 2015 / 64(RR02);1-26).

Persons exposed to smallpox should be vaccinated with a replication-competent vaccine, unless they are severely immunodeficient, according to a guideline from the Centers for Disease Control and Prevention.

© CDC

Severely immunodeficient persons won’t benefit from a smallpox vaccination because there will likely be a poor immune response and heightened risk of negative events. These include bone marrow transplant recipients within 4 months of transplantation, people infected with HIV with CD4 cell counts <50 cells/mm³, persons with severe combined immunodeficiency, complete DiGeorge syndrome patients, and people with other severely immunocompromised states requiring isolation.

“If antivirals are not immediately available, it is reasonable to consider the use of Imvamune in the setting of a smallpox virus exposure in persons with severe immunodeficiency,” the CDC added.

Find the full guideline in the MMWR (February 20, 2015 / 64(RR02);1-26).

NASHVILLE, TENN. – Last year, the Eighth Joint National Committee revised upward its classification of hypertension in healthy adults aged 60 years and older, recommending treatment when systolic pressure hits at least 150 mm Hg, or diastolic pressure reaches at least 90 mm Hg.

But raising the treatment cut point by 10 mm Hg from the earlier JNC 7 recommendations is a bad idea, Dr. Ralph L. Sacco warned at the International Stroke Conference – very bad, in fact.

And Dr. Sacco, the Olemberg Family Chair in Neurological Disorders at the University of Miami, said he has the data to prove it.

In a video interview at the meeting, Dr. Sacco outlined the findings from a new study exploring the stroke risks of patients who might find themselves now deemed normotensive under the JNC 8 hypertension guidelines.

[email protected]

On Twitter @alz_gal

NASHVILLE, TENN. – Last year, the Eighth Joint National Committee revised upward its classification of hypertension in healthy adults aged 60 years and older, recommending treatment when systolic pressure hits at least 150 mm Hg, or diastolic pressure reaches at least 90 mm Hg.

But raising the treatment cut point by 10 mm Hg from the earlier JNC 7 recommendations is a bad idea, Dr. Ralph L. Sacco warned at the International Stroke Conference – very bad, in fact.

And Dr. Sacco, the Olemberg Family Chair in Neurological Disorders at the University of Miami, said he has the data to prove it.

In a video interview at the meeting, Dr. Sacco outlined the findings from a new study exploring the stroke risks of patients who might find themselves now deemed normotensive under the JNC 8 hypertension guidelines.

[email protected]

On Twitter @alz_gal

NASHVILLE, TENN. – Last year, the Eighth Joint National Committee revised upward its classification of hypertension in healthy adults aged 60 years and older, recommending treatment when systolic pressure hits at least 150 mm Hg, or diastolic pressure reaches at least 90 mm Hg.

But raising the treatment cut point by 10 mm Hg from the earlier JNC 7 recommendations is a bad idea, Dr. Ralph L. Sacco warned at the International Stroke Conference – very bad, in fact.

And Dr. Sacco, the Olemberg Family Chair in Neurological Disorders at the University of Miami, said he has the data to prove it.

In a video interview at the meeting, Dr. Sacco outlined the findings from a new study exploring the stroke risks of patients who might find themselves now deemed normotensive under the JNC 8 hypertension guidelines.

[email protected]

On Twitter @alz_gal

The American Society of Clinical Oncology has endorsed the American Cancer Society Prostate Cancer Survivorship Care Guidelines, a 39-point list with recommendations on continuing care for prostate care survivors, but with a number of qualifying statements and modifications.

The guidelines, developed by a workgroup of 16 multidisciplinary experts specializing in the care of prostate cancer patients and the long-term effects of their treatments, are intended as points of reference for primary care providers, medical oncologists, urologists, and other health care providers.

Areas covered in the guidelines include health promotion, surveillance for recurrence, screening and early detection of second primary cancers, assessment and management of physical and psychosocial long-term and late effects, and care coordination and practice implications.Read the full list of recommendations here: (doi: 10.1200/JCO.2014.60.2557).

The American Society of Clinical Oncology has endorsed the American Cancer Society Prostate Cancer Survivorship Care Guidelines, a 39-point list with recommendations on continuing care for prostate care survivors, but with a number of qualifying statements and modifications.

The guidelines, developed by a workgroup of 16 multidisciplinary experts specializing in the care of prostate cancer patients and the long-term effects of their treatments, are intended as points of reference for primary care providers, medical oncologists, urologists, and other health care providers.

Areas covered in the guidelines include health promotion, surveillance for recurrence, screening and early detection of second primary cancers, assessment and management of physical and psychosocial long-term and late effects, and care coordination and practice implications.Read the full list of recommendations here: (doi: 10.1200/JCO.2014.60.2557).

The American Society of Clinical Oncology has endorsed the American Cancer Society Prostate Cancer Survivorship Care Guidelines, a 39-point list with recommendations on continuing care for prostate care survivors, but with a number of qualifying statements and modifications.

The guidelines, developed by a workgroup of 16 multidisciplinary experts specializing in the care of prostate cancer patients and the long-term effects of their treatments, are intended as points of reference for primary care providers, medical oncologists, urologists, and other health care providers.

Areas covered in the guidelines include health promotion, surveillance for recurrence, screening and early detection of second primary cancers, assessment and management of physical and psychosocial long-term and late effects, and care coordination and practice implications.Read the full list of recommendations here: (doi: 10.1200/JCO.2014.60.2557).

First-line treatment for allergic rhinitis should include intranasal steroids, as well as less-sedating second-generation oral antihistamines for patients whose primary complaints are sneezing and itching, according to a new clinical practice guideline published online Feb. 2 in Otolaryngology–Head and Neck Surgery.

In contrast, sinonasal imaging should not be routine when patients first present with symptoms consistent with allergic rhinitis, and oral leukotriene receptor antagonists are not recommended as first-line therapy, said Dr. Michael D. Seidman of Henry Ford West Bloomfield (Mich.) Hospital and chair of the guideline working group, and his associates.

©goa_novi/thinkstockphotos.com

Dr. Seidman and a panel of 20 experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advanced practice nursing, complementary and alternative medicine, and consumer advocacy developed the new practice guideline to enable clinicians in all settings to improve patient care and reduce harmful or unnecessary variations in care for allergic rhinitis.

“The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing allergic rhinitis,” the authors noted.

During the course of 1 year, the working group reviewed 1,605 randomized, controlled trials, 31 existing clinical practice guidelines, and 390 systematic reviews of the literature regarding allergic rhinitis in adults and children older than age 2 years. They then compiled 14 key recommendations that underwent extensive peer review, which have been published online and as a supplement to the February issue (Otolaryngol. Head Neck Surg. 2015;152:S1-S43).

In addition to the recommendations noted above, the guideline advises:

* Clinicians should diagnose allergic rhinitis when patients present with a history and physical exam consistent with the disorder (including clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red, watery eyes) plus symptoms of nasal congestion, runny nose, itchy nose, or sneezing.

* Clinicians should perform and interpret (or refer patients for) specific IgE allergy testing for allergic rhinitis that doesn’t respond to empiric treatment, or when the diagnosis is uncertain, or when identifying the specific causative allergen would allow targeted therapy.

* Clinicians should assess diagnosed patients for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, and should document that in the medical record.

* Clinicians should offer (or refer patients for) sublingual or subcutaneous immunotherapy when allergic rhinitis doesn’t respond adequately to pharmacologic therapy.

* Clinicians may advise avoidance of known allergens or controlling the patient’s environment by such measures as removing pets, using air filtration systems, using dust-mite–reducing covers for bedding, and using acaricides.

* Clinicians may offer intranasal antihistamines for patients with seasonal, perennial or episodic allergic rhinitis.*

* Clinicians may offer (or refer patients for) reduction of the inferior turbinates for patients who have nasal airway obstruction or enlarged turbinates.

* Clinicians may offer (or refer patient for) acupuncture if they are interested in nonpharmacologic therapy.

*Clinicians may offer combination pharmacologic therapy in patients with allergic rhinitis who have inadequate response to pharmacologic monotherapy.

The working group offered no recommendations concerning herbal therapy for allergic rhinitis, because of the limited literature on those substances and concern about their safety.

The full text of the guideline and its supporting data are available free of charge at www.entnet.org. In addition, an algorithm of the guideline’s action statements and a table of common allergic rhinitis clinical scenarios are available as quick reference guides for clinicians.

The American Academy of Otolaryngology–Head and Neck Surgery Foundation funded the guideline. Dr. Seidman reported being medical director of the Scientific Advisory Board of Visalus, founder of the Body Language Vitamin, and holder of six patents related to dietary supplements, aircraft, and middle ear and brain implants. His associates reported ties to Acclarent/Johnson/Johnson, FirstLine Medical, GlaxoSmithKline, Intersect, MEDA, Medtronic, Merck, Mylan, Novartis, TEVA, Transit of Venus, Sanofi, Sunovion Pharmaceuticals, and WellPoint.

*Correction, 2/18/2015: An earlier version of this story misstated the guideline for the use of intranasal antihistamines.

First-line treatment for allergic rhinitis should include intranasal steroids, as well as less-sedating second-generation oral antihistamines for patients whose primary complaints are sneezing and itching, according to a new clinical practice guideline published online Feb. 2 in Otolaryngology–Head and Neck Surgery.

In contrast, sinonasal imaging should not be routine when patients first present with symptoms consistent with allergic rhinitis, and oral leukotriene receptor antagonists are not recommended as first-line therapy, said Dr. Michael D. Seidman of Henry Ford West Bloomfield (Mich.) Hospital and chair of the guideline working group, and his associates.

©goa_novi/thinkstockphotos.com

Dr. Seidman and a panel of 20 experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advanced practice nursing, complementary and alternative medicine, and consumer advocacy developed the new practice guideline to enable clinicians in all settings to improve patient care and reduce harmful or unnecessary variations in care for allergic rhinitis.

“The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing allergic rhinitis,” the authors noted.

During the course of 1 year, the working group reviewed 1,605 randomized, controlled trials, 31 existing clinical practice guidelines, and 390 systematic reviews of the literature regarding allergic rhinitis in adults and children older than age 2 years. They then compiled 14 key recommendations that underwent extensive peer review, which have been published online and as a supplement to the February issue (Otolaryngol. Head Neck Surg. 2015;152:S1-S43).

In addition to the recommendations noted above, the guideline advises:

* Clinicians should diagnose allergic rhinitis when patients present with a history and physical exam consistent with the disorder (including clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red, watery eyes) plus symptoms of nasal congestion, runny nose, itchy nose, or sneezing.

* Clinicians should perform and interpret (or refer patients for) specific IgE allergy testing for allergic rhinitis that doesn’t respond to empiric treatment, or when the diagnosis is uncertain, or when identifying the specific causative allergen would allow targeted therapy.

* Clinicians should assess diagnosed patients for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, and should document that in the medical record.

* Clinicians should offer (or refer patients for) sublingual or subcutaneous immunotherapy when allergic rhinitis doesn’t respond adequately to pharmacologic therapy.

* Clinicians may advise avoidance of known allergens or controlling the patient’s environment by such measures as removing pets, using air filtration systems, using dust-mite–reducing covers for bedding, and using acaricides.

* Clinicians may offer intranasal antihistamines for patients with seasonal, perennial or episodic allergic rhinitis.*

* Clinicians may offer (or refer patients for) reduction of the inferior turbinates for patients who have nasal airway obstruction or enlarged turbinates.

* Clinicians may offer (or refer patient for) acupuncture if they are interested in nonpharmacologic therapy.

*Clinicians may offer combination pharmacologic therapy in patients with allergic rhinitis who have inadequate response to pharmacologic monotherapy.

The working group offered no recommendations concerning herbal therapy for allergic rhinitis, because of the limited literature on those substances and concern about their safety.

The full text of the guideline and its supporting data are available free of charge at www.entnet.org. In addition, an algorithm of the guideline’s action statements and a table of common allergic rhinitis clinical scenarios are available as quick reference guides for clinicians.

The American Academy of Otolaryngology–Head and Neck Surgery Foundation funded the guideline. Dr. Seidman reported being medical director of the Scientific Advisory Board of Visalus, founder of the Body Language Vitamin, and holder of six patents related to dietary supplements, aircraft, and middle ear and brain implants. His associates reported ties to Acclarent/Johnson/Johnson, FirstLine Medical, GlaxoSmithKline, Intersect, MEDA, Medtronic, Merck, Mylan, Novartis, TEVA, Transit of Venus, Sanofi, Sunovion Pharmaceuticals, and WellPoint.

*Correction, 2/18/2015: An earlier version of this story misstated the guideline for the use of intranasal antihistamines.

First-line treatment for allergic rhinitis should include intranasal steroids, as well as less-sedating second-generation oral antihistamines for patients whose primary complaints are sneezing and itching, according to a new clinical practice guideline published online Feb. 2 in Otolaryngology–Head and Neck Surgery.

In contrast, sinonasal imaging should not be routine when patients first present with symptoms consistent with allergic rhinitis, and oral leukotriene receptor antagonists are not recommended as first-line therapy, said Dr. Michael D. Seidman of Henry Ford West Bloomfield (Mich.) Hospital and chair of the guideline working group, and his associates.

©goa_novi/thinkstockphotos.com

Dr. Seidman and a panel of 20 experts in otolaryngology, allergy and immunology, internal medicine, family medicine, pediatrics, sleep medicine, advanced practice nursing, complementary and alternative medicine, and consumer advocacy developed the new practice guideline to enable clinicians in all settings to improve patient care and reduce harmful or unnecessary variations in care for allergic rhinitis.

“The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing allergic rhinitis,” the authors noted.

During the course of 1 year, the working group reviewed 1,605 randomized, controlled trials, 31 existing clinical practice guidelines, and 390 systematic reviews of the literature regarding allergic rhinitis in adults and children older than age 2 years. They then compiled 14 key recommendations that underwent extensive peer review, which have been published online and as a supplement to the February issue (Otolaryngol. Head Neck Surg. 2015;152:S1-S43).

In addition to the recommendations noted above, the guideline advises:

* Clinicians should diagnose allergic rhinitis when patients present with a history and physical exam consistent with the disorder (including clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red, watery eyes) plus symptoms of nasal congestion, runny nose, itchy nose, or sneezing.

* Clinicians should perform and interpret (or refer patients for) specific IgE allergy testing for allergic rhinitis that doesn’t respond to empiric treatment, or when the diagnosis is uncertain, or when identifying the specific causative allergen would allow targeted therapy.

* Clinicians should assess diagnosed patients for associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media, and should document that in the medical record.

* Clinicians should offer (or refer patients for) sublingual or subcutaneous immunotherapy when allergic rhinitis doesn’t respond adequately to pharmacologic therapy.

* Clinicians may advise avoidance of known allergens or controlling the patient’s environment by such measures as removing pets, using air filtration systems, using dust-mite–reducing covers for bedding, and using acaricides.

* Clinicians may offer intranasal antihistamines for patients with seasonal, perennial or episodic allergic rhinitis.*

* Clinicians may offer (or refer patients for) reduction of the inferior turbinates for patients who have nasal airway obstruction or enlarged turbinates.

* Clinicians may offer (or refer patient for) acupuncture if they are interested in nonpharmacologic therapy.

*Clinicians may offer combination pharmacologic therapy in patients with allergic rhinitis who have inadequate response to pharmacologic monotherapy.

The working group offered no recommendations concerning herbal therapy for allergic rhinitis, because of the limited literature on those substances and concern about their safety.

The full text of the guideline and its supporting data are available free of charge at www.entnet.org. In addition, an algorithm of the guideline’s action statements and a table of common allergic rhinitis clinical scenarios are available as quick reference guides for clinicians.

The American Academy of Otolaryngology–Head and Neck Surgery Foundation funded the guideline. Dr. Seidman reported being medical director of the Scientific Advisory Board of Visalus, founder of the Body Language Vitamin, and holder of six patents related to dietary supplements, aircraft, and middle ear and brain implants. His associates reported ties to Acclarent/Johnson/Johnson, FirstLine Medical, GlaxoSmithKline, Intersect, MEDA, Medtronic, Merck, Mylan, Novartis, TEVA, Transit of Venus, Sanofi, Sunovion Pharmaceuticals, and WellPoint.

*Correction, 2/18/2015: An earlier version of this story misstated the guideline for the use of intranasal antihistamines.

Antihypertensive therapy would prevent about 56,000 cardiovascular events annually and 13,000 deaths from strokes, myocardial infarctions, and other causes if it were used by all U.S. adults who qualify for treatment under 2014 Joint National Committee hypertension guidelines, according to computer modeling published online Jan. 28 in the New England Journal of Medicine.

Even though the new Joint Committee guidelines are a bit less stringent than the committee’s prior 2003 advice, blood pressure remains inadequately controlled in 44% of the 64 million U.S. adults with hypertension, according to the investigators, led by Dr. Andrew Moran of Columbia University Medical Center, New York (N. Engl. J. Med. 2015;372:447-55).

The team used data from the National Health and Nutrition Examination Survey, the Framingham Heart Study, and other sources to estimate costs and benefits of expanding treatment to all U.S. adults aged 35-74 years who meet the 2014 benchmarks. They then calculated cost-effectiveness of expanding use in various subpopulations, using $50,000/quality-adjusted life-year (QALY) gained, or less, as their cut-off.

Overall, the investigators found that fuller implementation of the Joint Committee goals would pay for itself in reduced cardiovascular morbidity and mortality. The results were driven primarily by secondary prevention in patients with cardiovascular disease and primary prevention in patients with stage 2 hypertension, meaning systolic BP of 160 mm Hg or higher or diastolic BP of 100 mm Hg or higher.

“There is an enormous potential for improving population health by expanding treatment and improving control. Our findings clearly show that it would be worthwhile to significantly increase spending on office visits, home blood pressure monitoring, and interventions to improve treatment adherence. In fact, we could double treatment and monitoring spending for some patients – namely those with severe hypertension – and still break even,” Dr. Moran said in a statement announcing the results.

Treatment of patients with existing cardiovascular disease or stage 2 hypertension would save lives and costs in all men 35-74 years old and in women aged 45-74 years. The treatment of more modest hypertension – systolic BP of 140-159 mm Hg or a diastolic BP of 90-99 mm Hg – was cost effective for all men and for women also between the ages of 45 and 74 years, but treating women 35-44 years old with moderate hypertension and diabetes or kidney disease had intermediate cost-effectiveness ($125,000 per QALY), and low cost-effectiveness ($181,000 per QALY) if those comorbidities were not present.

“Some people will be alarmed about our conclusion that it may not be cost effective to treat hypertension in young adults, especially young women. It’s worth noting that our analysis didn’t capture the cumulative, lifetime effects of hypertension. It may well turn out to be cost effective to treat this group if we look at data on costs and benefits over several decades,” Dr. Moran said.

The team assumed a medication adherence rate of 75%. The costs of treatment included medications, monitoring, and drug side effects.

They did not analyze the effect of diet and lifestyle interventions for lowering blood pressure, or compare the cost-effectiveness of specific antihypertensive medication classes or combinations.

The work was funded by the National Heart, Lung, and Blood Institute, among others. The authors reported no relevant financial disclosures.

[email protected]

Antihypertensive therapy would prevent about 56,000 cardiovascular events annually and 13,000 deaths from strokes, myocardial infarctions, and other causes if it were used by all U.S. adults who qualify for treatment under 2014 Joint National Committee hypertension guidelines, according to computer modeling published online Jan. 28 in the New England Journal of Medicine.

Even though the new Joint Committee guidelines are a bit less stringent than the committee’s prior 2003 advice, blood pressure remains inadequately controlled in 44% of the 64 million U.S. adults with hypertension, according to the investigators, led by Dr. Andrew Moran of Columbia University Medical Center, New York (N. Engl. J. Med. 2015;372:447-55).

The team used data from the National Health and Nutrition Examination Survey, the Framingham Heart Study, and other sources to estimate costs and benefits of expanding treatment to all U.S. adults aged 35-74 years who meet the 2014 benchmarks. They then calculated cost-effectiveness of expanding use in various subpopulations, using $50,000/quality-adjusted life-year (QALY) gained, or less, as their cut-off.

Overall, the investigators found that fuller implementation of the Joint Committee goals would pay for itself in reduced cardiovascular morbidity and mortality. The results were driven primarily by secondary prevention in patients with cardiovascular disease and primary prevention in patients with stage 2 hypertension, meaning systolic BP of 160 mm Hg or higher or diastolic BP of 100 mm Hg or higher.

“There is an enormous potential for improving population health by expanding treatment and improving control. Our findings clearly show that it would be worthwhile to significantly increase spending on office visits, home blood pressure monitoring, and interventions to improve treatment adherence. In fact, we could double treatment and monitoring spending for some patients – namely those with severe hypertension – and still break even,” Dr. Moran said in a statement announcing the results.

Treatment of patients with existing cardiovascular disease or stage 2 hypertension would save lives and costs in all men 35-74 years old and in women aged 45-74 years. The treatment of more modest hypertension – systolic BP of 140-159 mm Hg or a diastolic BP of 90-99 mm Hg – was cost effective for all men and for women also between the ages of 45 and 74 years, but treating women 35-44 years old with moderate hypertension and diabetes or kidney disease had intermediate cost-effectiveness ($125,000 per QALY), and low cost-effectiveness ($181,000 per QALY) if those comorbidities were not present.

“Some people will be alarmed about our conclusion that it may not be cost effective to treat hypertension in young adults, especially young women. It’s worth noting that our analysis didn’t capture the cumulative, lifetime effects of hypertension. It may well turn out to be cost effective to treat this group if we look at data on costs and benefits over several decades,” Dr. Moran said.

The team assumed a medication adherence rate of 75%. The costs of treatment included medications, monitoring, and drug side effects.

They did not analyze the effect of diet and lifestyle interventions for lowering blood pressure, or compare the cost-effectiveness of specific antihypertensive medication classes or combinations.

The work was funded by the National Heart, Lung, and Blood Institute, among others. The authors reported no relevant financial disclosures.

[email protected]

Antihypertensive therapy would prevent about 56,000 cardiovascular events annually and 13,000 deaths from strokes, myocardial infarctions, and other causes if it were used by all U.S. adults who qualify for treatment under 2014 Joint National Committee hypertension guidelines, according to computer modeling published online Jan. 28 in the New England Journal of Medicine.

Even though the new Joint Committee guidelines are a bit less stringent than the committee’s prior 2003 advice, blood pressure remains inadequately controlled in 44% of the 64 million U.S. adults with hypertension, according to the investigators, led by Dr. Andrew Moran of Columbia University Medical Center, New York (N. Engl. J. Med. 2015;372:447-55).

The team used data from the National Health and Nutrition Examination Survey, the Framingham Heart Study, and other sources to estimate costs and benefits of expanding treatment to all U.S. adults aged 35-74 years who meet the 2014 benchmarks. They then calculated cost-effectiveness of expanding use in various subpopulations, using $50,000/quality-adjusted life-year (QALY) gained, or less, as their cut-off.

Overall, the investigators found that fuller implementation of the Joint Committee goals would pay for itself in reduced cardiovascular morbidity and mortality. The results were driven primarily by secondary prevention in patients with cardiovascular disease and primary prevention in patients with stage 2 hypertension, meaning systolic BP of 160 mm Hg or higher or diastolic BP of 100 mm Hg or higher.

“There is an enormous potential for improving population health by expanding treatment and improving control. Our findings clearly show that it would be worthwhile to significantly increase spending on office visits, home blood pressure monitoring, and interventions to improve treatment adherence. In fact, we could double treatment and monitoring spending for some patients – namely those with severe hypertension – and still break even,” Dr. Moran said in a statement announcing the results.

Treatment of patients with existing cardiovascular disease or stage 2 hypertension would save lives and costs in all men 35-74 years old and in women aged 45-74 years. The treatment of more modest hypertension – systolic BP of 140-159 mm Hg or a diastolic BP of 90-99 mm Hg – was cost effective for all men and for women also between the ages of 45 and 74 years, but treating women 35-44 years old with moderate hypertension and diabetes or kidney disease had intermediate cost-effectiveness ($125,000 per QALY), and low cost-effectiveness ($181,000 per QALY) if those comorbidities were not present.

“Some people will be alarmed about our conclusion that it may not be cost effective to treat hypertension in young adults, especially young women. It’s worth noting that our analysis didn’t capture the cumulative, lifetime effects of hypertension. It may well turn out to be cost effective to treat this group if we look at data on costs and benefits over several decades,” Dr. Moran said.

The team assumed a medication adherence rate of 75%. The costs of treatment included medications, monitoring, and drug side effects.

They did not analyze the effect of diet and lifestyle interventions for lowering blood pressure, or compare the cost-effectiveness of specific antihypertensive medication classes or combinations.

The work was funded by the National Heart, Lung, and Blood Institute, among others. The authors reported no relevant financial disclosures.

[email protected]

The American College of Obstetricians and Gynecologists has added nifedipine as a first-line treatment for acute-onset severe hypertension during pregnancy and the postpartum period in an updated opinion from its Committee on Obstetric Practice.

The update, released on Jan. 22, points to studies showing that women who received oral nifedipine had their blood pressure lowered more quickly than with either intravenous labetalol or hydralazine – the traditional first-line treatments – and had a significant increase in urine output. Concerns about neuromuscular blockade and severe hypotension with the use of nifedipine and magnesium sulphate were not borne out in a large review, the committee members wrote, but they advised careful monitoring since both drugs are calcium antagonists.

The committee opinion includes model order sets for the use of labetalol, hydralazine, and nifedipine for the initial management of acute onset severe hypertension in women who are pregnant or post partum with preeclampsia or eclampsia (Obstet. Gynecol. 2015;125:521-5).

While all three medications are appropriate in treating hypertensive emergencies during pregnancy, each drug has adverse effects.

For instance, parenteral hydralazine can increase the risk of maternal hypotension. Parenteral labetalol may cause neonatal bradycardia and should be avoided in women with asthma, heart disease, or heart failure. Nifedipine has been associated with increased maternal heart rate and overshoot hypotension.

“Patients may respond to one drug and not another,” the committee noted.

The ACOG committee also called for standardized clinical guidelines for the management of patients with preeclampsia and eclampsia.

“With the advent of pregnancy hypertension guidelines in the United Kingdom, care of maternity patients with preeclampsia or eclampsia improved significantly and maternal mortality rates decreased because of a reduction in cerebral and respiratory complications,” they wrote. “Individuals and institutions should have mechanisms in place to initiate the prompt administration of medication when a patient presents with a hypertensive emergency.”

The committee recommended checklists as one tool to help standardize the use of guidelines.

The American College of Obstetricians and Gynecologists has added nifedipine as a first-line treatment for acute-onset severe hypertension during pregnancy and the postpartum period in an updated opinion from its Committee on Obstetric Practice.

The update, released on Jan. 22, points to studies showing that women who received oral nifedipine had their blood pressure lowered more quickly than with either intravenous labetalol or hydralazine – the traditional first-line treatments – and had a significant increase in urine output. Concerns about neuromuscular blockade and severe hypotension with the use of nifedipine and magnesium sulphate were not borne out in a large review, the committee members wrote, but they advised careful monitoring since both drugs are calcium antagonists.

The committee opinion includes model order sets for the use of labetalol, hydralazine, and nifedipine for the initial management of acute onset severe hypertension in women who are pregnant or post partum with preeclampsia or eclampsia (Obstet. Gynecol. 2015;125:521-5).

While all three medications are appropriate in treating hypertensive emergencies during pregnancy, each drug has adverse effects.

For instance, parenteral hydralazine can increase the risk of maternal hypotension. Parenteral labetalol may cause neonatal bradycardia and should be avoided in women with asthma, heart disease, or heart failure. Nifedipine has been associated with increased maternal heart rate and overshoot hypotension.

“Patients may respond to one drug and not another,” the committee noted.

The ACOG committee also called for standardized clinical guidelines for the management of patients with preeclampsia and eclampsia.

“With the advent of pregnancy hypertension guidelines in the United Kingdom, care of maternity patients with preeclampsia or eclampsia improved significantly and maternal mortality rates decreased because of a reduction in cerebral and respiratory complications,” they wrote. “Individuals and institutions should have mechanisms in place to initiate the prompt administration of medication when a patient presents with a hypertensive emergency.”

The committee recommended checklists as one tool to help standardize the use of guidelines.

The American College of Obstetricians and Gynecologists has added nifedipine as a first-line treatment for acute-onset severe hypertension during pregnancy and the postpartum period in an updated opinion from its Committee on Obstetric Practice.

The update, released on Jan. 22, points to studies showing that women who received oral nifedipine had their blood pressure lowered more quickly than with either intravenous labetalol or hydralazine – the traditional first-line treatments – and had a significant increase in urine output. Concerns about neuromuscular blockade and severe hypotension with the use of nifedipine and magnesium sulphate were not borne out in a large review, the committee members wrote, but they advised careful monitoring since both drugs are calcium antagonists.

The committee opinion includes model order sets for the use of labetalol, hydralazine, and nifedipine for the initial management of acute onset severe hypertension in women who are pregnant or post partum with preeclampsia or eclampsia (Obstet. Gynecol. 2015;125:521-5).

While all three medications are appropriate in treating hypertensive emergencies during pregnancy, each drug has adverse effects.

For instance, parenteral hydralazine can increase the risk of maternal hypotension. Parenteral labetalol may cause neonatal bradycardia and should be avoided in women with asthma, heart disease, or heart failure. Nifedipine has been associated with increased maternal heart rate and overshoot hypotension.

“Patients may respond to one drug and not another,” the committee noted.

The ACOG committee also called for standardized clinical guidelines for the management of patients with preeclampsia and eclampsia.

“With the advent of pregnancy hypertension guidelines in the United Kingdom, care of maternity patients with preeclampsia or eclampsia improved significantly and maternal mortality rates decreased because of a reduction in cerebral and respiratory complications,” they wrote. “Individuals and institutions should have mechanisms in place to initiate the prompt administration of medication when a patient presents with a hypertensive emergency.”

The committee recommended checklists as one tool to help standardize the use of guidelines.

New guidelines on nail psoriasis address four clinical manifestations of the disease. The recommendations by the Medical Board of the National Psoriasis Foundation appeared as a consensus statement in the January issue of JAMA Dermatology.

Limitations in clinical trial data make comparing treatments difficult, noted lead author Dr. Jeffrey J. Crowley of Bakersfield (Calif.) Dermatology and his associates. “There are limited data to evaluate or support the use of combination therapy in nail psoriasis. Thus, treatment options recommended in this review are monotherapy,” the guidelines authors added (JAMA Dermatol. 2015;151:87-94).

©Jim Pruitt/thinkstockphotos.com

To develop the guidelines, the research team searched PubMed for articles on nail psoriasis dating from Jan. 1, 1947 through May 11, 2014. They evaluated these studies for level of evidence based on recommendations for writing guidelines from Dr. Paul G. Shekelle of the VA West Los Angeles Medical Center and his associates (BMJ 1999;318:593-6).

They also polled the Medical Board of the National Psoriasis Foundation regarding their treatment approach for four clinical presentations of nail psoriasis:

• For treatment-naive patients with psoriasis of the nails only (affecting at least 3 of 10 fingernails), the board recommended initial treatment with high-potency topical corticosteroids (with or without calcipotriol), with intralesional corticosteroids as a secondary option. Intralesional corticosteroids have been used for decades, but clinical data supporting their use are “extremely limited,” the guidelines state.

• For extensive nail psoriasis (affecting at least five fingernails and causing moderate to severe pain) that has failed topical treatment, the board recommended adalimumab most enthusiastically, followed by etanercept, intralesional corticosteroids, ustekinumab, methotrexate sodium, and acitretin in decreasing order.

• For concurrent skin and nail disease without joint involvement (defined as skin disease on at least 8% of the body surface and moderately to severely painful dystrophy of at least 5 of 10 nails), the board strongly recommended adalimumab, etanercept, and ustekinumab, and also recommended methotrexate, acitretin, infliximab, and apremilast.

• For concurrent nail, skin, and joint involvement (defined as skin disease on 8% of the body surface, a history of dactylitis and morning stiffness (psoriatic arthritis), and severe, painful involvement of at least 5 of 10 nails), the board most strongly recommended adalimumab, followed by etanercept, ustekinumab, infliximab, methotrexate, apremilast, and golimumab.

Because nails grow slowly, psoriatic joint and skin disease often improve before nail psoriasis does, the authors noted. “Few studies show any significant improvement before 12 weeks, and several studies with etanercept, infliximab, and ustekinumab demonstrate continued improvement beyond 6 months,” they wrote.

About half of patients with psoriasis have some amount of nail involvement, and about 70% of patients with psoriatic arthritis have nail disease, according to the literature review. Dermatophyte infections can further complicate treatment of nail psoriasis, and immunosuppressive therapies can lead to onychomycosis in patients whose psoriasis includes the toenails, the authors added.

Dr. Crowley reported speaker and consulting honoraria from AbbVie, Abbott, and Amgen, and research funding from Abbott, AbbVie, Amgen, AstraZeneca, Celgene, Eli Lilly, Janssen Pharmaceutica, Merck, Pfizer, and Regeneron Pharmaceuticals. Four coauthors reported advisory, consulting, or financial relationships with Amgen, Abbott, Janssen Biotech Inc., Celgene, Novartis International AG, Abbvie, Merck, Celgene, Leo Pharma, Eli Lilly, Pfizer, and the National Psoriasis Foundation.

New guidelines on nail psoriasis address four clinical manifestations of the disease. The recommendations by the Medical Board of the National Psoriasis Foundation appeared as a consensus statement in the January issue of JAMA Dermatology.

Limitations in clinical trial data make comparing treatments difficult, noted lead author Dr. Jeffrey J. Crowley of Bakersfield (Calif.) Dermatology and his associates. “There are limited data to evaluate or support the use of combination therapy in nail psoriasis. Thus, treatment options recommended in this review are monotherapy,” the guidelines authors added (JAMA Dermatol. 2015;151:87-94).

©Jim Pruitt/thinkstockphotos.com

To develop the guidelines, the research team searched PubMed for articles on nail psoriasis dating from Jan. 1, 1947 through May 11, 2014. They evaluated these studies for level of evidence based on recommendations for writing guidelines from Dr. Paul G. Shekelle of the VA West Los Angeles Medical Center and his associates (BMJ 1999;318:593-6).

They also polled the Medical Board of the National Psoriasis Foundation regarding their treatment approach for four clinical presentations of nail psoriasis:

• For treatment-naive patients with psoriasis of the nails only (affecting at least 3 of 10 fingernails), the board recommended initial treatment with high-potency topical corticosteroids (with or without calcipotriol), with intralesional corticosteroids as a secondary option. Intralesional corticosteroids have been used for decades, but clinical data supporting their use are “extremely limited,” the guidelines state.

• For extensive nail psoriasis (affecting at least five fingernails and causing moderate to severe pain) that has failed topical treatment, the board recommended adalimumab most enthusiastically, followed by etanercept, intralesional corticosteroids, ustekinumab, methotrexate sodium, and acitretin in decreasing order.

• For concurrent skin and nail disease without joint involvement (defined as skin disease on at least 8% of the body surface and moderately to severely painful dystrophy of at least 5 of 10 nails), the board strongly recommended adalimumab, etanercept, and ustekinumab, and also recommended methotrexate, acitretin, infliximab, and apremilast.

• For concurrent nail, skin, and joint involvement (defined as skin disease on 8% of the body surface, a history of dactylitis and morning stiffness (psoriatic arthritis), and severe, painful involvement of at least 5 of 10 nails), the board most strongly recommended adalimumab, followed by etanercept, ustekinumab, infliximab, methotrexate, apremilast, and golimumab.

Because nails grow slowly, psoriatic joint and skin disease often improve before nail psoriasis does, the authors noted. “Few studies show any significant improvement before 12 weeks, and several studies with etanercept, infliximab, and ustekinumab demonstrate continued improvement beyond 6 months,” they wrote.

About half of patients with psoriasis have some amount of nail involvement, and about 70% of patients with psoriatic arthritis have nail disease, according to the literature review. Dermatophyte infections can further complicate treatment of nail psoriasis, and immunosuppressive therapies can lead to onychomycosis in patients whose psoriasis includes the toenails, the authors added.

Dr. Crowley reported speaker and consulting honoraria from AbbVie, Abbott, and Amgen, and research funding from Abbott, AbbVie, Amgen, AstraZeneca, Celgene, Eli Lilly, Janssen Pharmaceutica, Merck, Pfizer, and Regeneron Pharmaceuticals. Four coauthors reported advisory, consulting, or financial relationships with Amgen, Abbott, Janssen Biotech Inc., Celgene, Novartis International AG, Abbvie, Merck, Celgene, Leo Pharma, Eli Lilly, Pfizer, and the National Psoriasis Foundation.

New guidelines on nail psoriasis address four clinical manifestations of the disease. The recommendations by the Medical Board of the National Psoriasis Foundation appeared as a consensus statement in the January issue of JAMA Dermatology.

Limitations in clinical trial data make comparing treatments difficult, noted lead author Dr. Jeffrey J. Crowley of Bakersfield (Calif.) Dermatology and his associates. “There are limited data to evaluate or support the use of combination therapy in nail psoriasis. Thus, treatment options recommended in this review are monotherapy,” the guidelines authors added (JAMA Dermatol. 2015;151:87-94).

©Jim Pruitt/thinkstockphotos.com

To develop the guidelines, the research team searched PubMed for articles on nail psoriasis dating from Jan. 1, 1947 through May 11, 2014. They evaluated these studies for level of evidence based on recommendations for writing guidelines from Dr. Paul G. Shekelle of the VA West Los Angeles Medical Center and his associates (BMJ 1999;318:593-6).

They also polled the Medical Board of the National Psoriasis Foundation regarding their treatment approach for four clinical presentations of nail psoriasis:

• For treatment-naive patients with psoriasis of the nails only (affecting at least 3 of 10 fingernails), the board recommended initial treatment with high-potency topical corticosteroids (with or without calcipotriol), with intralesional corticosteroids as a secondary option. Intralesional corticosteroids have been used for decades, but clinical data supporting their use are “extremely limited,” the guidelines state.

• For extensive nail psoriasis (affecting at least five fingernails and causing moderate to severe pain) that has failed topical treatment, the board recommended adalimumab most enthusiastically, followed by etanercept, intralesional corticosteroids, ustekinumab, methotrexate sodium, and acitretin in decreasing order.

• For concurrent skin and nail disease without joint involvement (defined as skin disease on at least 8% of the body surface and moderately to severely painful dystrophy of at least 5 of 10 nails), the board strongly recommended adalimumab, etanercept, and ustekinumab, and also recommended methotrexate, acitretin, infliximab, and apremilast.

• For concurrent nail, skin, and joint involvement (defined as skin disease on 8% of the body surface, a history of dactylitis and morning stiffness (psoriatic arthritis), and severe, painful involvement of at least 5 of 10 nails), the board most strongly recommended adalimumab, followed by etanercept, ustekinumab, infliximab, methotrexate, apremilast, and golimumab.

Because nails grow slowly, psoriatic joint and skin disease often improve before nail psoriasis does, the authors noted. “Few studies show any significant improvement before 12 weeks, and several studies with etanercept, infliximab, and ustekinumab demonstrate continued improvement beyond 6 months,” they wrote.

About half of patients with psoriasis have some amount of nail involvement, and about 70% of patients with psoriatic arthritis have nail disease, according to the literature review. Dermatophyte infections can further complicate treatment of nail psoriasis, and immunosuppressive therapies can lead to onychomycosis in patients whose psoriasis includes the toenails, the authors added.

Dr. Crowley reported speaker and consulting honoraria from AbbVie, Abbott, and Amgen, and research funding from Abbott, AbbVie, Amgen, AstraZeneca, Celgene, Eli Lilly, Janssen Pharmaceutica, Merck, Pfizer, and Regeneron Pharmaceuticals. Four coauthors reported advisory, consulting, or financial relationships with Amgen, Abbott, Janssen Biotech Inc., Celgene, Novartis International AG, Abbvie, Merck, Celgene, Leo Pharma, Eli Lilly, Pfizer, and the National Psoriasis Foundation.

Most patients with diabetes should receive at least a moderate statin dosage regardless of their cardiovascular disease risk profile, according to the American Diabetes Association’s annual update to standards for managing patients with diabetes.

“Standards of Medical Care in Diabetes–2015” also shifts the ADA’s official recommendation on assessing patients for statin treatment from a decision based on blood levels of low density lipoprotein (LDL) cholesterol to a risk-based assessment. That change brings the ADA’s position in line with the approach advocated in late 2013 by guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) (J. Am. Coll. Cardiol. 2014;63:2889-934).

The ADA released the revised standards online Dec. 23.

The statin use recommendation is “a major change, a fairly big change in how we provide care, although not that big a change in what most patients are prescribed,” said Dr. Richard W. Grant, a primary care physician and researcher at Kaiser Permanente Northern California in Oakland and chair of the ADA’s Professional Practice Committee, the 14-member panel that produced the revised standards.

“We agreed [with the 2013 ACC and AHA lipid guidelines] that the decision to start a statin should be based on a patient’s cardiovascular disease risk, and it turns out that nearly every patient with type 2 diabetes should be on a statin,” Dr. Grant said in an interview.

The revised standards recommend a “moderate” statin dosage for patients with diabetes who are aged 40-75 years, as well as those who are older than 75 years even if they have no other cardiovascular disease risk factors (Diabetes Care 2015;38:S1-S94).

The dosage should be intensified to “high” for patients with diagnosed cardiovascular disease, and for patients aged 40-75 years with other cardiovascular disease risk factors. For patients older than 75 years with cardiovascular disease risk factors, the new revision calls for either a moderate or high dosage.

However, for patients younger than 40 years with no cardiovascular disease or risk factors, the revised standards call for no statin treatment, a moderate or high dosage for patients younger than 40 years with risk factors, and a high dosage for those with cardiovascular disease.

The ADA’s recommendation for no statin treatment of the youngest and lowest-risk patients with diabetes is somewhat at odds with the 2013 ACC and AHA recommendations. For this patient group, those recommendations said, “statin therapy should be individualized on the basis of considerations of atherosclerotic cardiovascular disease risk-reduction benefits, the potential for adverse effects and drug-drug interactions, and patient preferences.”

The new standards revision contains several other changes, including:

• The recommended goal diastolic blood pressure for patients with diabetes was revised to less than 90 mm Hg, an increase from the 80–mm Hg target that had been in place. That change follows a revision in the ADA’s 2014 standards that increased the systolic blood pressure target to less than 140 mm Hg.

Changing the diastolic target to less than 90 mm Hg was primarily a matter of following the best evidence that exists in the literature, Dr. Grant said, because only lower-grade evidence supports a target of less than 80 mm Hg.

The revised standards also note that the new targets of less than 140/90 mm Hg put the standards “ in harmonization” with the 2014 recommendations of the panel originally assembled at the Eighth Joint National Committee (JAMA 2014;311:507-20).

• The recommended blood glucose target when measured before eating is now 80-130 mg/dL, with the lower limit increased from 70 mg/dL. That change reflects new data that correlate blood glucose levels with blood levels of hemoglobin A_1c.

• The revision sets the body mass index cutpoint for screening overweight or obese Asian Americans at 23 kg/m², an increase from the prior cutpoint of 25 kg/m².

• A new section devoted to managing patients with diabetes during pregnancy draws together information that previously had been scattered throughout the standards document, Dr. Grant explained. The section discusses gestational diabetes management, as well as managing women who had preexisting type 1 or type 2 diabetes prior to becoming pregnant.

Dr. Grant had no disclosures.

[email protected]

On Twitter @mitchelzoler

Most patients with diabetes should receive at least a moderate statin dosage regardless of their cardiovascular disease risk profile, according to the American Diabetes Association’s annual update to standards for managing patients with diabetes.

“Standards of Medical Care in Diabetes–2015” also shifts the ADA’s official recommendation on assessing patients for statin treatment from a decision based on blood levels of low density lipoprotein (LDL) cholesterol to a risk-based assessment. That change brings the ADA’s position in line with the approach advocated in late 2013 by guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) (J. Am. Coll. Cardiol. 2014;63:2889-934).

The ADA released the revised standards online Dec. 23.

The statin use recommendation is “a major change, a fairly big change in how we provide care, although not that big a change in what most patients are prescribed,” said Dr. Richard W. Grant, a primary care physician and researcher at Kaiser Permanente Northern California in Oakland and chair of the ADA’s Professional Practice Committee, the 14-member panel that produced the revised standards.

“We agreed [with the 2013 ACC and AHA lipid guidelines] that the decision to start a statin should be based on a patient’s cardiovascular disease risk, and it turns out that nearly every patient with type 2 diabetes should be on a statin,” Dr. Grant said in an interview.

The revised standards recommend a “moderate” statin dosage for patients with diabetes who are aged 40-75 years, as well as those who are older than 75 years even if they have no other cardiovascular disease risk factors (Diabetes Care 2015;38:S1-S94).

The dosage should be intensified to “high” for patients with diagnosed cardiovascular disease, and for patients aged 40-75 years with other cardiovascular disease risk factors. For patients older than 75 years with cardiovascular disease risk factors, the new revision calls for either a moderate or high dosage.

However, for patients younger than 40 years with no cardiovascular disease or risk factors, the revised standards call for no statin treatment, a moderate or high dosage for patients younger than 40 years with risk factors, and a high dosage for those with cardiovascular disease.

The ADA’s recommendation for no statin treatment of the youngest and lowest-risk patients with diabetes is somewhat at odds with the 2013 ACC and AHA recommendations. For this patient group, those recommendations said, “statin therapy should be individualized on the basis of considerations of atherosclerotic cardiovascular disease risk-reduction benefits, the potential for adverse effects and drug-drug interactions, and patient preferences.”

The new standards revision contains several other changes, including:

• The recommended goal diastolic blood pressure for patients with diabetes was revised to less than 90 mm Hg, an increase from the 80–mm Hg target that had been in place. That change follows a revision in the ADA’s 2014 standards that increased the systolic blood pressure target to less than 140 mm Hg.

Changing the diastolic target to less than 90 mm Hg was primarily a matter of following the best evidence that exists in the literature, Dr. Grant said, because only lower-grade evidence supports a target of less than 80 mm Hg.

The revised standards also note that the new targets of less than 140/90 mm Hg put the standards “ in harmonization” with the 2014 recommendations of the panel originally assembled at the Eighth Joint National Committee (JAMA 2014;311:507-20).

• The recommended blood glucose target when measured before eating is now 80-130 mg/dL, with the lower limit increased from 70 mg/dL. That change reflects new data that correlate blood glucose levels with blood levels of hemoglobin A_1c.

• The revision sets the body mass index cutpoint for screening overweight or obese Asian Americans at 23 kg/m², an increase from the prior cutpoint of 25 kg/m².

• A new section devoted to managing patients with diabetes during pregnancy draws together information that previously had been scattered throughout the standards document, Dr. Grant explained. The section discusses gestational diabetes management, as well as managing women who had preexisting type 1 or type 2 diabetes prior to becoming pregnant.

Dr. Grant had no disclosures.

[email protected]

On Twitter @mitchelzoler

Most patients with diabetes should receive at least a moderate statin dosage regardless of their cardiovascular disease risk profile, according to the American Diabetes Association’s annual update to standards for managing patients with diabetes.

“Standards of Medical Care in Diabetes–2015” also shifts the ADA’s official recommendation on assessing patients for statin treatment from a decision based on blood levels of low density lipoprotein (LDL) cholesterol to a risk-based assessment. That change brings the ADA’s position in line with the approach advocated in late 2013 by guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) (J. Am. Coll. Cardiol. 2014;63:2889-934).

The ADA released the revised standards online Dec. 23.

The statin use recommendation is “a major change, a fairly big change in how we provide care, although not that big a change in what most patients are prescribed,” said Dr. Richard W. Grant, a primary care physician and researcher at Kaiser Permanente Northern California in Oakland and chair of the ADA’s Professional Practice Committee, the 14-member panel that produced the revised standards.

“We agreed [with the 2013 ACC and AHA lipid guidelines] that the decision to start a statin should be based on a patient’s cardiovascular disease risk, and it turns out that nearly every patient with type 2 diabetes should be on a statin,” Dr. Grant said in an interview.

The revised standards recommend a “moderate” statin dosage for patients with diabetes who are aged 40-75 years, as well as those who are older than 75 years even if they have no other cardiovascular disease risk factors (Diabetes Care 2015;38:S1-S94).

The dosage should be intensified to “high” for patients with diagnosed cardiovascular disease, and for patients aged 40-75 years with other cardiovascular disease risk factors. For patients older than 75 years with cardiovascular disease risk factors, the new revision calls for either a moderate or high dosage.

However, for patients younger than 40 years with no cardiovascular disease or risk factors, the revised standards call for no statin treatment, a moderate or high dosage for patients younger than 40 years with risk factors, and a high dosage for those with cardiovascular disease.

The ADA’s recommendation for no statin treatment of the youngest and lowest-risk patients with diabetes is somewhat at odds with the 2013 ACC and AHA recommendations. For this patient group, those recommendations said, “statin therapy should be individualized on the basis of considerations of atherosclerotic cardiovascular disease risk-reduction benefits, the potential for adverse effects and drug-drug interactions, and patient preferences.”

The new standards revision contains several other changes, including:

• The recommended goal diastolic blood pressure for patients with diabetes was revised to less than 90 mm Hg, an increase from the 80–mm Hg target that had been in place. That change follows a revision in the ADA’s 2014 standards that increased the systolic blood pressure target to less than 140 mm Hg.

Changing the diastolic target to less than 90 mm Hg was primarily a matter of following the best evidence that exists in the literature, Dr. Grant said, because only lower-grade evidence supports a target of less than 80 mm Hg.

The revised standards also note that the new targets of less than 140/90 mm Hg put the standards “ in harmonization” with the 2014 recommendations of the panel originally assembled at the Eighth Joint National Committee (JAMA 2014;311:507-20).

• The recommended blood glucose target when measured before eating is now 80-130 mg/dL, with the lower limit increased from 70 mg/dL. That change reflects new data that correlate blood glucose levels with blood levels of hemoglobin A_1c.

• The revision sets the body mass index cutpoint for screening overweight or obese Asian Americans at 23 kg/m², an increase from the prior cutpoint of 25 kg/m².

• A new section devoted to managing patients with diabetes during pregnancy draws together information that previously had been scattered throughout the standards document, Dr. Grant explained. The section discusses gestational diabetes management, as well as managing women who had preexisting type 1 or type 2 diabetes prior to becoming pregnant.

Dr. Grant had no disclosures.

[email protected]

On Twitter @mitchelzoler

Physicians should use ambulatory blood pressure screening to confirm elevated office measurements before diagnosing hypertension, according to a draft recommendation from the U.S. Preventive Services Task Force.

Because high blood pressure affects nearly a third of U.S. adults, the USPSTF recommends screening all adults for high blood pressure, based on good evidence that screening and treatment reduce cardiovascular events with few major harms.

However, blood pressure fluctuates with emotion, stress, pain, physical activity, medications, and even the presence of health care providers. So, the USPSTF issued a draft, A-level recommendation to use ambulatory or home blood pressure monitoring following an initial elevated screening to confirm a diagnosis of hypertension, except when initiating therapy immediately is medically necessary.

Patients with blood pressure at or above 180/110 mm Hg or evidence of end-organ damage should begin drug therapy immediately. In addition, patients diagnosed with secondary hypertension do not need ambulatory monitoring confirmation.

The USPSTF recommendations are based on a meta-analysis published Dec. 22 (Ann. Intern. Med. 2014: [doi10.7326/M14-1539]. Although the evidence for ambulatory screening confirmation was of good quality, the evidence base is less robust for home monitoring, the task force noted.

“Our evidence review shows that overdiagnosis of hypertension from unconfirmed office-based screening could result in unnecessary treatment in a substantial number of persons,” reported Margaret A. Piper, Ph.D., of Kaiser Permanente Center for Health Research, Portland, Ore., and her associates in the study. “Ambulatory BP monitoring provides multiple measurements over time in a nonmedical setting, which potentially avoids measurement error, regression to the mean, and misdiagnosis of isolated clinic hypertension, and is best correlated with long-term outcomes.”

Dr. Piper’s team searched for good- and fair-quality studies in MEDLINE, PubMed, the Cochrane Central Register of Controlled Trials and CINAHL through August 2014, yielding 1 trial for the benefits of screening, 7 studies on the diagnostic accuracy of office blood pressure measurement, 11 studies on the diagnostic accuracy of ambulatory blood pressure measurement, 27 studies on using ambulatory screenings to confirm hypertension, 4 studies on harms of screening, and 40 studies on rescreening intervals and hypertension incidence in those with normal blood pressure.

The meta-analysis showed that 5%-65% of patients were not diagnosed with hypertension following ambulatory blood pressure monitoring after an initially elevated office screening measurement.

The USPSTF draft recommendation also noted past epidemiological evidence that 15%-30% of those diagnosed with hypertension may actually have lower blood pressure when not in a medical setting.

The meta-analysis also found that the risk of fatal and nonfatal stroke and cardiovascular events was “consistently and significantly associated with” elevated systolic ambulatory blood pressure, regardless of the measurements in an office.

The primary harms of screening identified in the study were greater absenteeism from work and greater illness episodes after diagnosis, as well as sleep disturbances, discomfort, and daily activity restrictions because of the ambulatory device.

On the basis of the evidence from the meta-analysis, the USPSTF recommended annual screenings for adults age 40 years and older and those at high risk for hypertension, including African Americans, those who are overweight or obese, and those with a normally high blood pressure (130-139/85-89 mm Hg). Screenings should occur every 3-5 years for those age 18-39 years with no risk factors and a normal blood pressure.

Target blood pressure should remain below 140/90 mm Hg for adults younger than 60 years, and below 150/90 mm Hg for adults 60 years or older with neither diabetes nor chronic kidney disease, according to guidelines from the Eighth Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.

The U.S. Agency for Healthcare Research and Quality funded the meta-analysis. The authors had no relevant disclosures.

Physicians should use ambulatory blood pressure screening to confirm elevated office measurements before diagnosing hypertension, according to a draft recommendation from the U.S. Preventive Services Task Force.

Because high blood pressure affects nearly a third of U.S. adults, the USPSTF recommends screening all adults for high blood pressure, based on good evidence that screening and treatment reduce cardiovascular events with few major harms.

However, blood pressure fluctuates with emotion, stress, pain, physical activity, medications, and even the presence of health care providers. So, the USPSTF issued a draft, A-level recommendation to use ambulatory or home blood pressure monitoring following an initial elevated screening to confirm a diagnosis of hypertension, except when initiating therapy immediately is medically necessary.

Patients with blood pressure at or above 180/110 mm Hg or evidence of end-organ damage should begin drug therapy immediately. In addition, patients diagnosed with secondary hypertension do not need ambulatory monitoring confirmation.

The USPSTF recommendations are based on a meta-analysis published Dec. 22 (Ann. Intern. Med. 2014: [doi10.7326/M14-1539]. Although the evidence for ambulatory screening confirmation was of good quality, the evidence base is less robust for home monitoring, the task force noted.

“Our evidence review shows that overdiagnosis of hypertension from unconfirmed office-based screening could result in unnecessary treatment in a substantial number of persons,” reported Margaret A. Piper, Ph.D., of Kaiser Permanente Center for Health Research, Portland, Ore., and her associates in the study. “Ambulatory BP monitoring provides multiple measurements over time in a nonmedical setting, which potentially avoids measurement error, regression to the mean, and misdiagnosis of isolated clinic hypertension, and is best correlated with long-term outcomes.”

Dr. Piper’s team searched for good- and fair-quality studies in MEDLINE, PubMed, the Cochrane Central Register of Controlled Trials and CINAHL through August 2014, yielding 1 trial for the benefits of screening, 7 studies on the diagnostic accuracy of office blood pressure measurement, 11 studies on the diagnostic accuracy of ambulatory blood pressure measurement, 27 studies on using ambulatory screenings to confirm hypertension, 4 studies on harms of screening, and 40 studies on rescreening intervals and hypertension incidence in those with normal blood pressure.

The meta-analysis showed that 5%-65% of patients were not diagnosed with hypertension following ambulatory blood pressure monitoring after an initially elevated office screening measurement.

The USPSTF draft recommendation also noted past epidemiological evidence that 15%-30% of those diagnosed with hypertension may actually have lower blood pressure when not in a medical setting.

The meta-analysis also found that the risk of fatal and nonfatal stroke and cardiovascular events was “consistently and significantly associated with” elevated systolic ambulatory blood pressure, regardless of the measurements in an office.

The primary harms of screening identified in the study were greater absenteeism from work and greater illness episodes after diagnosis, as well as sleep disturbances, discomfort, and daily activity restrictions because of the ambulatory device.

On the basis of the evidence from the meta-analysis, the USPSTF recommended annual screenings for adults age 40 years and older and those at high risk for hypertension, including African Americans, those who are overweight or obese, and those with a normally high blood pressure (130-139/85-89 mm Hg). Screenings should occur every 3-5 years for those age 18-39 years with no risk factors and a normal blood pressure.

Target blood pressure should remain below 140/90 mm Hg for adults younger than 60 years, and below 150/90 mm Hg for adults 60 years or older with neither diabetes nor chronic kidney disease, according to guidelines from the Eighth Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.

The U.S. Agency for Healthcare Research and Quality funded the meta-analysis. The authors had no relevant disclosures.

Physicians should use ambulatory blood pressure screening to confirm elevated office measurements before diagnosing hypertension, according to a draft recommendation from the U.S. Preventive Services Task Force.

Because high blood pressure affects nearly a third of U.S. adults, the USPSTF recommends screening all adults for high blood pressure, based on good evidence that screening and treatment reduce cardiovascular events with few major harms.

However, blood pressure fluctuates with emotion, stress, pain, physical activity, medications, and even the presence of health care providers. So, the USPSTF issued a draft, A-level recommendation to use ambulatory or home blood pressure monitoring following an initial elevated screening to confirm a diagnosis of hypertension, except when initiating therapy immediately is medically necessary.

Patients with blood pressure at or above 180/110 mm Hg or evidence of end-organ damage should begin drug therapy immediately. In addition, patients diagnosed with secondary hypertension do not need ambulatory monitoring confirmation.

The USPSTF recommendations are based on a meta-analysis published Dec. 22 (Ann. Intern. Med. 2014: [doi10.7326/M14-1539]. Although the evidence for ambulatory screening confirmation was of good quality, the evidence base is less robust for home monitoring, the task force noted.

“Our evidence review shows that overdiagnosis of hypertension from unconfirmed office-based screening could result in unnecessary treatment in a substantial number of persons,” reported Margaret A. Piper, Ph.D., of Kaiser Permanente Center for Health Research, Portland, Ore., and her associates in the study. “Ambulatory BP monitoring provides multiple measurements over time in a nonmedical setting, which potentially avoids measurement error, regression to the mean, and misdiagnosis of isolated clinic hypertension, and is best correlated with long-term outcomes.”

Dr. Piper’s team searched for good- and fair-quality studies in MEDLINE, PubMed, the Cochrane Central Register of Controlled Trials and CINAHL through August 2014, yielding 1 trial for the benefits of screening, 7 studies on the diagnostic accuracy of office blood pressure measurement, 11 studies on the diagnostic accuracy of ambulatory blood pressure measurement, 27 studies on using ambulatory screenings to confirm hypertension, 4 studies on harms of screening, and 40 studies on rescreening intervals and hypertension incidence in those with normal blood pressure.

The meta-analysis showed that 5%-65% of patients were not diagnosed with hypertension following ambulatory blood pressure monitoring after an initially elevated office screening measurement.

The USPSTF draft recommendation also noted past epidemiological evidence that 15%-30% of those diagnosed with hypertension may actually have lower blood pressure when not in a medical setting.

The meta-analysis also found that the risk of fatal and nonfatal stroke and cardiovascular events was “consistently and significantly associated with” elevated systolic ambulatory blood pressure, regardless of the measurements in an office.

The primary harms of screening identified in the study were greater absenteeism from work and greater illness episodes after diagnosis, as well as sleep disturbances, discomfort, and daily activity restrictions because of the ambulatory device.

On the basis of the evidence from the meta-analysis, the USPSTF recommended annual screenings for adults age 40 years and older and those at high risk for hypertension, including African Americans, those who are overweight or obese, and those with a normally high blood pressure (130-139/85-89 mm Hg). Screenings should occur every 3-5 years for those age 18-39 years with no risk factors and a normal blood pressure.

Target blood pressure should remain below 140/90 mm Hg for adults younger than 60 years, and below 150/90 mm Hg for adults 60 years or older with neither diabetes nor chronic kidney disease, according to guidelines from the Eighth Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.

The U.S. Agency for Healthcare Research and Quality funded the meta-analysis. The authors had no relevant disclosures.