GUIDELINE WATCH

2016

Coverage of the New Clinical Guidelines

Most Likely to Affect Your Practice Today
 October 2016

nejm journal watch Dear Reader,

Cardiology
Emergency Medicine Clinical guidelines are increasingly important in setting practice standards
Gastroenterology and meeting quality measures, and NEJM Journal Watch wants to help
General Medicine you keep up with the guidelines most important to your practice. Our
Hospital Medicine 90 clinician-editors regularly survey more than 250 medical journals to
Infectious Diseases identify the latest critical information. As part of this effort, we appraise
Neurology a broad range of clinical guidelines, choose those with the most clinical
Oncology and Hematology impact, and summarize them, highlighting key points and identifying
Pediatrics andAdolescent Medicine whats new, in a feature called Guideline Watch.
Psychiatry This collection of the most relevant Guideline Watches, published from
Womens Health October 2015 to September 2016, covers a range of guidelinesfrom new
CDC recommendations for prescribing opioids in the setting of chronic pain
to ADA standards of care for patients with diabetes and an AHA update
of its guidance on CPR and emergency cardiac carebut the common
denominator is their relevance to, and implications for, clinical practice.
We hope you enjoy this compilation and find it useful for providing the
best and most responsible patient care, and we invite you to interact with
us at JWatch.org.

Robert Dall
Editorial Director,
Clinical Programs,
NEJM Group

800.843.6356 | f: 781.891.1995 | nejmgroup@mms.org

860 winter street, waltham, ma 02451-1413
nejmgroup.org
Guideline Watch 2016

TABLE
OF CONTENTS
ADA Standards of Medical Care in Diabetes 4

Appropriate Antibiotic Use in Adults with Acute Respiratory Tract Infections 6

New CDC Guidelines for Prescribing Opioids for Patients with Chronic Pain 8

Infective Endocarditis in Adults 10

AHA CPR and Emergency Cardiac Care Guidelines: Updates for 2015 12

Updated Guidelines for Anticoagulation of Venous Thromboembolic Disease 14

Management of Acute Lower Gastrointestinal Bleeding 15

Barrett Esophagus: Updated Guideline Recommendations 17

Treating Adults with Helicobacter Pylori Infection: An Update 18

Updated Quality Measurement Set for Parkinson Disease Treatment 19

USPSTF Recommendations on Interventions for Smoking Cessation 21

Nonoccupational Postexposure Prophylaxis for HIV: Updated Guidelines 23

Guidelines for Acne Care and Management 25

NEJM Journal Watch is produced by NEJM Group, a division of the Massachusetts Medical Society.
2016 Massachusetts Medical Society. All rights reserved.
Guideline Watch 2016 jwatch.org

ADA Standards of Medical Care in Diabetes

Jamaluddin Moloo, MD, MPH, reviewing Chamberlain JJ et al. Ann Intern Med 2016 Mar 1.

A synopsis of the American Diabetes Associations 2016 guidelines

Sponsoring Organization: American Diabetes Association (ADA)

Target Audience: All clinicians providing care to patients with diabetes

Background
The ADA publishes a comprehensive update entitled Standards of Medical Care in Diabetes annually. Now, Annals
of Internal Medicine has published a concise 10-page synopsis of the full 2016 ADA document, highlighting areas of
particular importance to primary care physicians. The recommendations are assigned ratings of A, B, or C, depending
on the quality of evidence.

Key Recommendations
Diagnosing diabetes
A glycosylated hemoglobin (HbA1c) level of 5.7% to 6.4% is classified as prediabetic; an HbA1c level of 6.5% is
classified as diabetic.
Women with histories of gestational diabetes should be screened for diabetes at least every 3 years.

Monitoring and glycemic targets

HbA1c levels should be obtained at least twice yearly in diabetic patients on stable regimens who have achieved
their target HbA1c levels and quarterly in patients who dont meet these criteria.
HbA1c measurement alone is insufficient to evaluate glycemic variability or hypoglycemia; self-monitoring of
blood glucose is required.
The HbA1c goal for most nonpregnant adults is <7%. In young patients without other comorbidities, clinicians
might consider a more stringent target of <6.5%, whereas a less stringent target should be considered in patients
with extensive comorbid conditions or limited life expectancy.
Raising glycemic targets for several weeks can help reverse hypoglycemic unawareness.
For most noncritical hospitalized patients, blood glucose levels of 140 to 180 mg/dL are recommended (A rating);
for cardiac-surgery patients and those with acute ischemic cardiac or neurologic events, glucose levels of 110 to
140 mg/dL can be considered (C rating).

Medical management
Encourage a minimum of 150 minutes weekly of moderate-intensity aerobic activity.
Type 1 diabetes: Intensive insulin therapy (3 daily injections of insulin) or continuous subcutaneous insulin
(vs. 1 or 2 daily injections) clearly lowers risk for microvascular complications and adverse cardiovascular
outcomes.
Type 2 diabetes: Metformin is the preferred initial pharmacologic agent, and it can be used (with dose reductions)
in patients with glomerular filtration rates as low as 30 to 45 mL/minute/1.73 m2.
Hypertension treatment goal should be <140/90 mm Hg. The guideline specifically advises against a lower goal
(<130/70 mm Hg) in older patients. The initial antihypertensive agent should be an angiotensin-converting
enzyme inhibitor or an angiotensin-receptor blocker, but not both.

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Statins are recommended for most middle-aged or older individuals (age, 40). Adding ezetimibe to a moderate-
intensity statin can be considered for patients with recent acute coronary syndromes or for patients who are unable
to tolerate higher-dose statins. Combination therapy with a statin plus a fibrate generally is not recommended (A
rating). Similarly, combination therapy with a statin plus niacin is not recommended and might confer excess risk
for stroke (A rating).
Antiplatelet therapy: Low-dose aspirin is recommended for primary prevention of cardiovascular disease in
patients with type 1 and type 2 diabetes, if 10-year arteriosclerotic cardiovascular disease risk is >10%; it is not
recommended if risk is <5% (C rating).

Microvascular screening and management

Eye examinations: Retinal photographs alone are insufficient, and a complete eye exam should be performed
annually by an ophthalmologist or optometrist.
Peripheral neuropathy: FDA-approved medications to treat diabetic neuropathy include pregabalin, duloxetine,
and tapentadol. Other agents, including tricyclic antidepressants, gabapentin, venlafaxine and carbamazepine,
also can be considered.

COMMENT
This synopsis provides a quick snapshot of contemporary diabetes care standards. Clinicians should consult
the full ADA guideline for more depth and detail.

Chamberlain JJ et al. Diagnosis and management of diabetes: Synopsis of the 2016 American Diabetes Association
Standards of Medical Care in Diabetes. Ann Intern Med 2016 Mar 1; [e-pub]. (http://dx.doi.org/10.7326/M15-3016)

Jamaluddin Moloo, MD, MPH, is Associate Professor of Clinical Medicine, University of South Carolina School
of Medicine; Chief, Department of Medicine, Palmetto Health Richland Memorial Hospital; and adjunct
Associate Professor, University of South Carolina Arnold School of Public Health.

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Appropriate Antibiotic Use in Adults

with Acute Respiratory Tract Infections
Jamaluddin Moloo, MD, MPH, reviewing Harris AM et al. Ann Intern Med 2016 Jan 19.

Antibiotics should not be prescribed for most patients with uncomplicated bronchitis, sore throat, or acute
rhinosinusitis.
Sponsoring Organizations: American College of Physicians (ACP), Centers for Disease Control and Prevention (CDC)

Target Audience: All clinicians who provide care to adults in ambulatory settings

Background
Antibiotics are prescribed during more than 100 million adult ambulatory visits annually; an estimated 50% of these
prescriptions might be unnecessary or inappropriate. This paper from the ACP and the CDC is an update of 2001
guidelines on appropriate antibiotic use for acute respiratory tract infection in adults (NEJM JW Gen Med Apr 15 2001
and Ann Intern Med 2001; 134:479) and includes advice on managing bronchitis, pharyngitis, and rhinosinusitis. The
focus of the update is healthy adults without chronic lung disease or immunocompromising conditions.

Key Points and Recommendations

Acute uncomplicated bronchitis
More than 90% is viral; cough can last as long as 6 weeks and might be associated with mild constitutional
symptoms.
Purulent sputum or a change in its color does not signify bacterial infection; purulence results from the presence
of inflammatory cells or sloughed mucosal cells.
Patients might benefit from symptomatic relief (e.g., cough suppressants, expectorants).
It should be differentiated from pneumonia, which is unlikely in the absence of tachycardia, tachypnea, fever >38C,
and abnormal chest exam.
Clinicians should not perform testing or initiate antibiotics unless pneumonia is suspected.

Pharyngitis
Pharyngitis most often is viral; a viral etiology is more likely in patients with associated cough, nasal congestion,
conjunctivitis, or oral ulcers or vesicles.
Patients with fewer than three Centor criteria (i.e., fever by history, tonsillar exudates, tender anterior cervical
adenopathy, absence of cough) have a low probability of group A streptococcal infection and do not require
further testing.
Oral antibiotics (e.g., penicillin, amoxicillin) should be prescribed only if group A streptococcal pharyngitis is
confirmed.

Acute rhinosinusitis
Acute rhinosinusitis (duration range, 133 days) usually is caused by a viral infection associated with the
common cold; symptoms include nasal congestion, purulent nasal discharge, maxillary tooth pain, facial pain,
fever, and ear pain.
Acute bacterial rhinosinusitis can develop secondary to a viral upper respiratory infection (URI); however, fewer
than 2% of viral URIs are complicated by bacterial rhinosinusitis.

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Given the similar radiographic appearance of viral sinusitis and bacterial sinusitis, imaging is not helpful.
Antibiotics should be reserved for patients whose symptoms persist for >10 days, are severe (i.e., fever >39C,
purulent nasal discharge, facial pain for >3 consecutive days), or deteriorate after initial improvement. The 2012
Infectious Diseases of America guidelines recommend amoxicillin-clavulanate as the preferred agent if antibiotics
are deemed to be necessary.

COMMENT
Unnecessary antibiotic use contributes to drug resistance and preventable morbidity and mortality. Although
randomized trials have demonstrated that antibiotics are ineffective for most acute respiratory tract infections,
such infections are the most common reason for prescribing antibiotics in adults in ambulatory settings. The
authors acknowledge that patient demands might drive antibiotic misuse and offer guidance on how to address
patient expectations (e.g., label acute bronchitis as a chest cold or viral upper respiratory infection). The
CDC provides patient information sheets about appropriate antibiotic use and alternatives to antibiotics for
symptom management (http://www.cdc.gov/getsmart/community/materials-references/print-materials/
hcp/index.html).

Harris AM et al. Appropriate antibiotic use for acute respiratory tract infection in adults: Advice for high-value care from
the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med 2016 Jan 19;
[e-pub]. (http://dx.doi.org/10.7326/M15-1840)

Jamaluddin Moloo, MD, MPH, is Associate Professor of Clinical Medicine, University of South Carolina School
of Medicine; Chief, Department of Medicine, Palmetto Health Richland Memorial Hospital; and adjunct
Associate Professor, University of South Carolina Arnold School of Public Health.

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New CDC Guidelines for Prescribing Opioids for Patients

with Chronic Pain
Thomas L. Schwenk, MD, reviewing Dowell D et al.; Olsen Y.; and Lee TH. JAMA 2016 Mar 15.

Twelve recommendations focus on opioid use for chronic pain not related to cancer or end-of-life care.
Sponsoring Organization: Centers for Disease Control and Prevention (CDC)

Target Audience: Primary care clinicians

Background
About 20,000 people died from opioid overdoses in 2014; 3% to 4% of the U.S. population receive prescriptions for
long-term opioid therapy. The CDC has released what is considered to be the first federal clinical guideline for use
of opioids in adults with chronic pain (duration, >3 months) not related to cancer or end-of-life care. The guideline
is based on an update of a 2014 systematic review; at that time, no studies had evaluated benefits of opioid use for
1 year, but substantial risks of addiction, overdose, and death from long-term use had been documented.

Key Recommendations
The guideline comprises 12 recommendations:

Nonpharmacological (e.g. exercise, cognitive behavioral therapy) and nonopioid pharmacological therapies are
preferred for managing chronic pain.
Opioids should be prescribed only after setting clear treatment goals focused on both improving function and
decreasing pain.
Risks of opioid use for chronic pain should be discussed explicitly.
Immediate-release opioids are strongly, if not exclusively, preferred over extended-release or long-acting opioids;
methadone is not the preferred choice for a long-acting opioid and should only be used by clinicians with special
expertise.
Clinicians should initiate opioids at the lowest effective dose. When dosage must be escalated, doses should be
limited to 50 MMEs (morphine mg equivalents; 50 MMEs=50 mg of hydrocodone or 33 mg of oxycodone) daily
in most circumstances, and 90 MMEs daily without special justification.
Opioid prescriptions for acute pain should be limited to 3 days in most circumstances.
Benefits and harms of opioid therapy should be reviewed within 1 to 4 weeks of starting therapy or increasing
dose and regularly thereafter.
Opioid use should be avoided in patients with sleep-disordered breathing or with renal or hepatic insufficiency,
in those who are pregnant, and in elders (age, 65). Clinicians should consider making naloxone available for
patients at high risk for overdose.
Data from state prescription monitoring programs should be reviewed at the initiation of opioid therapy and
periodically thereafter.
Clinicians should consider using urine drug testing at initiation of opioid therapy and periodically thereafter.
Concomitant benzodiazepine use increases risk for overdose and should be avoided.
Clinicians should monitor patients for opioid-use disorder (addiction or excessive use) and arrange for
evidence-based treatment as needed.

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COMMENT
This guideline was portrayed as being directed specifically to primary care clinicians, but it should be directed
toward any clinician who provides chronic pain care to adults who are not receiving palliative or cancer care.
Clinicians can invoke this guideline during discussions with patients who insist on progressive opioid dose
escalation without good justification. An editorialist describes his personal practices in prescribing opioids
for chronic pain, including using only immediate-release opioids, never exceeding the 50 MME threshold,
prescribing only 1 month of medication at a time, never authorizing refills, deemphasizing pain scores and
assessments, and focusing on daily function.

Dowell D et al. CDC guideline for prescribing opioids for chronic pain United States, 2016. JAMA 2016 Mar 15;
[e-pub]. (http://dx.doi.org/10.1001/jama.2016.1464)
Olsen Y. The CDC guideline on opioid prescribing: Rising to the challenge. JAMA 2016 Mar 15; [e-pub]. (http://dx.doi.org/
10.1001/jama.2016.1910)
Lee TH. Zero pain is not the goal. JAMA 2016 Mar 15; [e-pub]. (http://dx.doi.org/10.1001/jama.2016.1912)

Thomas L. Schwenk, MD, is Dean, University of Nevada School of Medicine.

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Infective Endocarditis in Adults

Richard T. Ellison III, MD, reviewing Baddour LM et al. Circulation 2015 Oct 13.

An update to guidelines published in 2005, this new document continues to incorporate an evidence-based
scoring system but now provides the evidence level for each recommendation.
Sponsoring Organizations: American Heart Association and Infectious Diseases Society of America

Target Audience: Cardiac surgeons, cardiologists, general internists, hospitalists, infectious diseases specialists

Target Population: Patients with suspected or confirmed infective endocarditis (IE)

Background and Objective

The American Heart Associations recommendations for the diagnosis and management of IE were perhaps the
first major clinical practice guidelines in the field of infectious diseases. The new recommendations update those
from 2005; they continue to incorporate an evidence-based scoring system but now more precisely delineate each
recommendation with an evidence level.

Key Points
The recommendations on diagnosis and on use of echocardiography remain essentially unchanged. Additional
information is provided on the therapeutic principles of antimicrobial treatment, including more-detailed suggestions
on treatment duration.

Specific recommendations, including tables listing suggested antimicrobial agents and treatment durations for
particular pathogens, are again included, with a few revisions to the 2005 guidelines.

Whats Changed
The recommendation to consider gentamicin for treatment of staphylococcal native valve IE has been eliminated.
Daptomycin has been added as an alternative agent for treating IE caused by methicillin-sensitive or methicillin-
resistant staphylococci.
Recommendations are provided for patients with staphylococcal IE and concurrent brain abscess.
Recommendations on treating enterococcal IE now include use of double-lactam therapy with ampicillin and
high-dose ceftriaxone.
Linezolid, and high-dose daptomycin given alone or with a -lactam, are discussed as potential alternative
approaches for managing IE caused by enterococci resistant to penicillin, aminoglycosides, and vancomycin.
Specific antibiotic suggestions for treating culture-negative IE have been replaced by more-general recommenda-
tions based on expert assessment of epidemiological risk factors.
The discussion on surgical management now includes more details on the timing of interventions, valve surgery
for right-sided IE, and surgery in patients with recent stroke or subclinical cerebral emboli.
More-detailed recommendations are provided regarding follow-up after treatment and dental management
of IE patients.

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COMMENT
The American Heart Association and the Infectious Diseases Society of America have done the field of medi-
cine a great service in continuing to support the work of preparing and updating these guidelines. One would
only wish that the guidelines could be living documents comparable to those for HIV treatment and that they
could highlight modifications to past recommendations.

Larry M. Baddour, MD, and Robert S. Baltimore, MD, are among the authors of this study and members of the NEJM Journal Watch Infectious Diseases editorial
board but had no role in selecting or summarizing this article.

Baddour LM et al. Infective endocarditis in adults: Diagnosis, antimicrobial therapy, and management of complications:
A scientific statement for healthcare professionals from the American Heart Association. Circulation 2015 Oct 13;
132:1435. (http://dx.doi.org/10.1161/CIR.0000000000000296)

Richard T. Ellison III, MD, is Professor of Medicine, Microbiology & Physiological Systems, Division of
Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester.

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AHA CPR and Emergency Cardiac Care Guidelines:

Updates for 2015
Ali S. Raja, MD, MBA, MPH, FACEP, reviewing Neumar RW et al. Circulation 2015 Nov 3.

Push hard and fast but not too hard or too fast!
Sponsoring Organization: American Heart Association (AHA)

Target Population: Lay public, healthcare providers

Background and Objective

The AHA has released an evidence-based update to its 2010 guidelines for cardiopulmonary resuscitation (CPR) and
emergency cardiovascular care.

Key Points
Adult basic life support (BLS):
Bystanders should initiate compression-only CPR.
Compression rate should be 100120 per minute (updated from at least 100 per minute).
Compression depth should be 22.4 inches (upper limit added).
Compression time should be maximized.
Feedback devices may be used to optimize compression rate and depth.
Social media may be used to summon rescuers to perform CPR.

Adult advanced cardiovascular life support (ACLS):

Vasopressin is out; stick with epinephrine.
Extracorporeal CPR is an alternative to CPR in patients for whom the suspected etiology is reversible.
Maximize oxygenation during CPR, but titrate down after return of spontaneous circulation (ROSC).
After 20 minutes of CPR, a low end-tidal CO2 level may be used to help determine whether to terminate
resuscitation in intubated patients.
Ultrasound may be used to confirm endotracheal tube placement.

After ROSC:
Consider lidocaine if arrest is due to ventricular fibrillation/tachycardia.
In comatose patients, target temperature to 3236C for at least 24 hours, and prevent fever.

Emergency cardiac care:

A high-sensitivity troponin I level <99th percentile at 0 and 2 hours in a low-risk patient (Thrombolysis in
Myocardial Infarction I score of 0 or 1) predicts <1% chance of 30-day major adverse cardiac event).
A negative troponin I or T at 0 and 36 hours in a very low-risk patient (Vancouver score of 0) predicts
<1% chance of 30-day major adverse cardiac event.

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Whats Changed
The 2010 recommendations focused on increased compression depth and speed, but now we have good evidence that
too much of either is bad. In addition, new technologies (e.g., extracorporeal membrane oxygenation, high sensitivity
troponin assays, CPR feedback devices, social media) are included, and vasopressin is finally out again.

COMMENT
These well-written updates incorporate new evidence while acknowledging areas in which evidence is still
lacking. Given that these updates will soon be incorporated into BLS and ACLS training, it is important to
know about them so that we can effectively lead resuscitation teams (and avoid blank looks when erroneously
ordering vasopressin).

Neumar RW et al. 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency
cardiovascular care. Circulation 2015 Nov 3; 132:Suppl 2:S315. (http://dx.doi.org/10.1161/CIR.0000000000000252)

Ali S. Raja, MD, MBA, MPH, FACEP, is Vice Chair, Department of Emergency Medicine, Massachusetts General
Hospital, Boston; a faculty member of the Center for Evidence-Based Imaging at Brigham and Womens Hospital;
and Associate Professor, Harvard Medical School.

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Updated Guidelines for Anticoagulation

of Venous Thromboembolic Disease
Daniel M. Lindberg, MD, reviewing Kearon C et al. Chest 2016 Jan 7.

Newer anticoagulants get a boost, while catheter-directed thrombolysis is no longer recommended.

Sponsoring Organization: American College of Chest Physicians.

Target Population: Clinicians treating patients with pulmonary embolism (PE) or deep venous thrombosis (DVT)

Background
Since these guidelines were last published in 2012, the world of anticoagulation has been fundamentally changed by
the development of nonvitamin K oral anticoagulants (NOACs).

Key Recommendations
In patients with venous thromboembolic disease (VTE) without cancer, NOACs (dabigatran, rivaroxaban,
apixaban, or edoxaban) should be considered first-line therapy, followed by vitamin K antagonists (i.e., warfarin),
and then low molecular weight heparin (LMWH).
In patients with VTE and cancer, LMWH is first line therapy, then warfarin, and finally NOACs.
For low-risk, isolated, subsegmental PE, clinical surveillance is recommended, rather than anticoagulation.
Thrombolysis should almost always be reserved for hypotensive patients, and should be given systemically, rather
than catheter-directed.
For isolated distal DVT of the leg, the choice between anticoagulation and serial ultrasound at 2 weeks should be
made based on risk for thrombus extension, risk for bleeding, and patient preference.
Home treatment is recommended for patients with low-risk PE.
Patients should be switched to LMWH if they have recurrent VTE on another therapy; patients with recurrent
VTE on LMWH should have their dose increased.

COMMENT
These guidelines are complex but valuable and could save a patient from unnecessary anticoagulation and
admission. The published guidelines include important details about risk for bleeding or clot extension. These
guidelines should move to the front of the line for translation into clinical pathways or electronic decision
support.

At the time NEJM Journal Watch reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Kearon C et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016 Jan 7;
[e-pub]. (http://dx.doi.org/10.1016/j.chest.2015.11.026)

Daniel M. Lindberg, MD, is attending physician, Department of Emergency Medicine and Kempe Center for the
Prevention and Treatment of Child Abuse and Neglect, University of Colorado School of Medicine.

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Management of Acute Lower Gastrointestinal Bleeding

Douglas K. Rex, MD, reviewing Strate LL and Gralnek IM. Am J Gastroenterol 2016 Apr; 111:459.

A new ACG guideline is practical and comprehensive albeit based on low-quality evidence.
Sponsoring Organization: American College of Gastroenterology (ACG)

Target Audience: Gastroenterologists and emergency physicians primarily, and general surgeons and primary care
providers secondarily

Background and Objective

In a new ACG clinical guideline on management of acute overt lower gastrointestinal (GI) bleeding, researchers
developed evidence-based recommendations based on a systematic literature review. They defined lower GI bleeding
as colorectal bleeding and not small-bowel bleeding, which has historically been included in the definition.

Key Recommendations
Perform upper endoscopy for hematochezia with hemodynamic instability.
Use a nasogastric tube to assess upper GI bleeding if suspicion is moderate; it can be left in place for colonic
lavage.
Colonoscopy is the initial diagnostic test of choice for nearly all patients. In the small group of patients unable
to be stabilized for colonoscopy, perform radiographic tests.
As part of resuscitation, attempt to normalize blood pressure and heart rate prior to endoscopy.
The general transfusion goal should be >7 g/dL, the same as for upper GI bleeding, though if massive bleeding
or cardiovascular ischemia is present, consider increasing it to 9 g/dL.
Include terminal ileum intubation and detailed inspection of the colon during colonoscopy.
Prep the patient with 4 to 6 liters of a polyethylene glycolbased solution until the rectal effluent is clear. (The
authors oppose unprepped colonoscopy or sigmoidoscopy.)
When necessary, use a nasogastric tube to deliver lavage; accompany it with prokinetic agents, and take aspiration
precautions in the elderly.
Perform colonoscopy within 24 hours when bleeding is ongoing.
Hemostatic clips are preferred over thermal treatments for diverticular bleeding. Rubber band ligation and over-
the-scope clips have been safely used.
Use argon plasma coagulation for angiectasia, with pretreatment submucosal injection for right colon lesions.
Use hemostatic clips for postpolypectomy bleeding.
In general, do not use epinephrine injection as the sole treatment for active bleeding.
Discontinue nonaspirin nonsteroidal anti-inflammatory drugs to prevent bleeding recurrence.
In patients at high risk for cardiovascular disease, continue aspirin for secondary prevention after cessation
of bleeding, and avoid aspirin for primary prevention in most patients.
Management of high-risk patients with thromboembolic events, including those on dual antiplatelet therapy,
warfarin, novel oral anticoagulants, etc., sometimes requires consultation with multiple specialists including
cardiologists, hematologists, and neurologists.

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Consider co-transfusion of platelets and fresh frozen plasma in patients receiving more than 10 units of packed
red blood cells in a 24-hour period or 3 units within 1 hour.

COMMENT
Though many of the recommendations in this guideline are graded as strong, virtually all of the supporting
evidence is of low or very low quality. Nevertheless, the guideline is very practical and comprehensive and
passes the common sense test. The only recommendation here that I personally do not follow is to lavage pa-
tients passing bright red blood after polypectomy, because the bleeding source is typically so easy to find and
treat without preparation.

Strate LL and Gralnek IM. ACG clinical guideline: Management of patients with acute lower gastrointestinal bleeding.
Am J Gastroenterol 2016 Apr; 111:459. (http://dx.doi.org/10.1038/ajg.2016.41)

Douglas K. Rex, MD, is Professor of Medicine and Director of Endoscopy, Division of Gastroenterology and
Hepatology, Indiana University Medical Center, Indianapolis.

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Barrett Esophagus: Updated Guideline Recommendations

David A. Johnson, MD, reviewing Shaheen NJ et al. Am J Gastroenterol 2015 Nov 3.

Routine screening in women with gastroesophageal reflux disorder is not recommended.

Sponsoring Organization: American College of Gastroenterology (ACG)

Target Audience: Gastroenterologists, general internists

Background and Objective

Considerable controversy surrounds the cost-effectiveness of screening and surveillance for Barrett esophagus (BE)
as well as the role of ablative therapies aimed at decreasing the related esophageal adenocarcinoma (EAC) risk. The
ACG has evaluated the most current published clinical reports on this topic and now offers evidence-based, weighted
recommendations on current best practices.

Key Recommendations
Screening
Do not routinely screen women with gastroesophageal reflux disease (GERD) symptoms.
Screen men with chronic (lasting >5 years) GERD symptoms and 2 risk factors for BE or EAC (age >50 years,
Caucasian race, central obesity, current or past smoking history, and confirmed family history of BE or EAC).

Endoscopy
Do not perform biopsy if Z line is normal or has <1 cm of variability.
Use the Prague classification for reporting the circumferential and maximal segment length.
If the initial screening shows erosive esophagitis, repeat the exam to exclude BE after treating the patient for 8 to
12 weeks with a proton-pump inhibitor to heal esophagitis.

Endoscopic ablative therapy

Expand use to patients with low-grade dysplasia (LGD).
Do not use in patients with nondysplastic BE and no dysplasia on endoscopic mucosal resection (EMR).
Use in patients with low-grade or high-grade dysplastic lesions after complete resection by EMR.
Continue endoscopic surveillance following ablative therapy.

COMMENT
Of note, the clinical value of screening women with GERD for BE has been likened to the value of theoretical
routine screening for breast cancer in men. Also notable is the recommendation against routine screening of
men with GERD in the absence of other identified risks for BE or EAC. This new guideline is essential reading
for clinicians who evaluate patients with BE.

Shaheen NJ et al. ACG clinical guideline: Diagnosis and management of Barretts esophagus. Am J Gastroenterol 2015
Nov 3; [e-pub]. (http://dx.doi.org/10.1038/ajg.2015.322)

David A. Johnson, MD, is Professor of Medicine and Chief of Gastroenterology, Eastern Virginia School of
Medicine, Norfolk.

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Treating Adults with Helicobacter Pylori Infection: An Update

David J. Bjorkman, MD, MSPH (HSA), SM (Epid.), reviewing Fallone CA et al. Gastroenterology 2016 Apr 18.

New recommendations emphasize quadruple therapy and the need to understand local drug-resistance
patterns.
Sponsoring Organizations: The Canadian Association of Gastroenterology and the Canadian Helicobacter Study Group

Target Audience: Gastroenterologists, general practitioners, and other clinicians who treat adult patients

Background
Treating patients with Helicobacter pylori infection is becoming increasingly difficult because of increasing antibiotic
resistance. An expert panel recently convened to systematically review the literature and make specific recommenda-
tions regarding eradication therapy in adults. The panel members rated the strength of the recommendations and the
quality of the evidence using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE)
methodology and assessed their level of agreement with the statements using a modified Delphi approach.

Strong Recommendations
Initial treatment should be for 14 days.
Decisions regarding first-line therapy should be based on local antibiotic resistance.
Recommended regimens for first-line treatment included bismuth-based quadruple therapy and non-bismuth
proton-pump inhibitor (PPI)-based quadruple therapy.
PPI-based triple therapy should be restricted to areas where clarithromycin resistance is less than 15%
or eradication success is greater than 85%.
Levofloxacin triple therapy and sequential PPI-based triple therapy are not recommended.
Recommended salvage therapies after initial treatment therapy are bismuth-based quadruple therapy and
levofloxacin triple therapy (the latter is a conditional recommendation); sequential therapy is not recommended.
Patients who fail to respond to clarithromycin- or levofloxacin-containing therapies should not use regimens
containing those agents for salvage therapy.
Rifabutin-containing regimens should be reserved until after failure of three other therapies.
The routine addition of probiotics to reduce adverse events is not recommended.

COMMENT
These recommendations emphasize the need for an understanding of local drug-resistance patterns in
selecting therapies for H. pylori and suggest that first-line therapy should be quadruple therapy (bismuth
or PPI-based) for 14 days.

At the time NEJM Journal Watch reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Fallone CA et al. The Toronto consensus for the treatment of Helicobacter pylori infection in adults. Gastroenterology
2016 Apr 18; S0016-5085(16)30108-1. (http://dx.doi.org/10.1053/j.gastro.2016.04.006)

David J. Bjorkman, MD, MSPH (HSA), SM (Epid.), is Dean, Charles E. Schmidt College of Medicine, Florida
Atlantic University, and President, World Gastroenterology Organization.

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Updated Quality Measurement Set for Parkinson Disease Treatment

Michael S. Okun, MD, reviewing Factor SA et al. Neurology 2016 May 11.

Some simple quality measures aim to improve Parkinson disease care in the clinic setting.
Sponsoring Organization: American Academy of Neurology (AAN)

Target Audience: Clinicians who treat patients with Parkinson disease (PD), including movement disorder specialists,
other neurologists, and primary care clinicians

Background and Objective

The AAN updated its 2010 measurement set based on new evidence of gaps in care for patients with PD and research
showing opportunities to improve their care.

Key Recommendations
PD is the second most common neurodegenerative disorder. There is a pressing need to improve the quality of care
delivered by neurologists and other healthcare practitioners to patients with PD. In 2010, the AAN published the first
widely available quality measures on PD, designed to be used in the clinic setting. The idea of the measures was to
improve quality, but also to address potential gaps in care. The updated measures (all process measures, except as
noted) are as follows:

Review diagnosis.
Avoid dopamine blockers.
Review psychiatric symptoms.
Ask about cognitive impairment.
Review autonomic symptoms.
Ask about sleep disturbance.
Document falls (an outcome measure).
Offer rehabilitative therapy options.
Provide counseling on exercise.
Ask about medication-related complications.
Discuss advance care planning.

Whats Changed
The main enhancements from the 2010 quality measures are the promotion of tailored exercise for all patients with
PD and mention of access to interdisciplinary care and discussions of advance directives and advance care planning.
Documentation of falls was moved from a process measure to an outcome measure, with the goal of reducing or
eliminating falls.

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COMMENT
PD is perhaps the most complex of all diseases when considering all of the motor and nonmotor features,
medications, and surgical treatment options. It is therefore appropriate that every practitioner engaged in
the care of PD patients have a checklist to avoid overlooking important disease management domains. Even
experts in PD care could benefit from embedding these 11 practices into their regular patient management.

Factor SA et al. Quality improvement in neurology: Parkinson disease update quality measurement set. Executive
summary. Neurology 2016 May 11; [e-pub]. (http://dx.doi.org/10.1212/WNL.0000000000002670)

Michael S. Okun, MD, is Professor and Chairman, University of Florida Department of Neurology; Co-Director,
Center for Movement Disorders and Neurorestoration, and Adelaide Lackner Professor in Neurology, University
of Florida McKnight Brain Institute, Gainesville.

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USPSTF Recommendations on Interventions for Smoking Cessation

Jamaluddin Moloo, MD, MPH, reviewing Siu AL; and Patnode CD et al. Ann Intern Med 2015 Sep 22.

The U.S. Preventive Services Task Force provides an overview of best practices for helping patients succeed in
quitting.
Sponsoring Organization: U.S. Preventive Services Task Force (USPSTF)

Target Audience: Primary care clinicians

Background
Approximately 18% of U.S. adults smoke tobacco, and tobacco remains the leading preventable cause of morbidity and
mortality. The USPSTF has updated its 2009 recommendation on counseling and interventions to prevent tobacco use
(NEJM JW Gen Med Jun 1 2009 and Ann Intern Med 2009; 150:447).

Key Recommendations
Record a patients smoking behavior as a vital sign.
Use the 5 As:
Ask about smoking.
Advise patients to quit through personalized messages.
Assess a patients willingness to quit.
Assist quitting.
Arrange follow-up.
Interventions for nonpregnant adults:
Convincing evidence shows that behavioral interventions (i.e., counseling, self-help materials) improve cessation;
added to pharmacotherapy, they improve cessation rates by approximately 5%.
Convincing evidence shows that nicotine replacement therapy (i.e., patches, lozenges, gum, inhalers, nasal spray)
improves cessation rates (from 10% to 17%).
Bupropion SR and varenicline, with or without behavioral counseling, improves cessation rates (by approximately
8% and 16%, respectively).
Using two types of nicotine replacement therapy concurrently improves cessation rates relative to using one, and
nicotine replacement therapy adds benefit to bupropion alone.
Evidence was insufficient to evaluate use of electronic nicotine delivery systems (ENDS) as a smoking cessation
tool in adults and adolescents.
Interventions for pregnant women:
Behavioral interventions improve cessation rates.
Evidence is inadequate to recommend nicotine replacement therapy, and no evidence exists on bupropion SR,
varenicline, or ENDS.

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COMMENT
This guideline provides a useful overview of best practices toward achieving the difficult goal of smoking
abstinence. One point in the guideline that might be unfamiliar to clinicians is that concurrent use of two
nicotine-replacement modalities improves smoking cessation rates compared with using a single modality.
Whereas the USPSTF finds insufficient evidence to provide a recommendation on e-cigarettes as smoking
cessation aids, the American Heart Association has issued tentative support for e-cigarettes when other
methods have failed (Circulation 2014; 130:1418).

Siu AL. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant
women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015 Sep 22; 163:622.
(http://dx.doi.org/10.7326/M15-2023)
Patnode CD et al. Behavioral counseling and pharmacotherapy interventions for tobacco cessation in adults, including
pregnant women: A review of reviews for the U.S. Preventive Services Task Force. Ann Intern Med 2015 Sep 22;
163:608. (http://dx.doi.org/10.7326/M15-0171)

Jamaluddin Moloo, MD, MPH, is Associate Professor of Clinical Medicine, University of South Carolina School
of Medicine; Chief, Department of Medicine, Palmetto Health Richland Memorial Hospital; and adjunct
Associate Professor, University of South Carolina Arnold School of Public Health.

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Nonoccupational Postexposure Prophylaxis for HIV:

Updated Guidelines
Kevin Ard, MD, MPH, and Rajesh T. Gandhi, MD, reviewing Dominguez KL et al. MMWR Morb Mortal Wkly
Rep 2016 May 6.

Some helpful updates have been made to these guidelines.

Sponsoring Organization: Centers for Disease Control and Prevention, U.S. Department of Health and Human
Services

Target Audience: Clinicians who see patients for nonoccupational postexposure prophylaxis (nPEP) in the United
States

Background
This guideline updates the 2005 version. Because no randomized trials of nPEP have been done, recommendations are
based on data from animal transmission models, perinatal clinical trials, and observational and case studies.

Key Recommendations
Consider nPEP for individuals who present for medical care within 72 hours after sexual, mucosal, or percutaneous
exposure to potentially infectious bodily fluids from an HIV-infected person.
Make decisions about use of nPEP on a case-by-case basis when the sources HIV status is unknown but the
exposure confers a substantial risk for infection should the source have HIV.
Perform baseline HIV testing in all patients evaluated for nPEP. The new guideline recommends testing with a
rapid HIV antigen/antibody or antibody blood test. If a rapid test is not available, initiation of nPEP should not
be delayed while awaiting test results.
For nPEP, 28-day regimens are recommended. The preferred regimens are now tenofovir-FTC with either
raltegravir or dolutegravir. An alternative regimen is tenofovir-FTC with both darunavir and ritonavir. Routine
use of only two antiretroviral agents for nPEP is no longer recommended.
Following exposure by sexual assault, intramuscular ceftriaxone and either oral azithromycin or oral doxycycline
should be given to prevent gonorrhea and chlamydia. Women should also receive oral metronidazole or tinidazole
for prevention of trichomonas.
Provide hepatitis B vaccination for hepatitis B nonimmune individuals.
Perform follow-up HIV testing at 4 to 6 weeks and 3 months after exposure; testing at 6 months is now recom-
mended only for those who contract hepatitis C, which can delay HIV seroconversion.
Perform follow-up testing for hepatitis B and C 6 months after exposure in susceptible people.
For nPEP patients with high, ongoing risk for HIV infection, tenofovir-FTC can be continued for pre-exposure
prophylaxis (PrEP) when nPEP concludes, provided that follow-up HIV testing is negative (new recommendation).

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COMMENT
This guideline provides a welcome update to the recommended antiretroviral regimens for nPEP. The
preferred regimens are well-tolerated, have few drug interactions, and reflect what many clinicians are
already prescribing. The guidance on transitioning between nPEP and PrEP is helpful, as many patients
seeking nPEP have high, ongoing risk for HIV infection and thus may benefit from PrEP. A limitation of
the document is the sparse guidance on nPEP use for exposures from a source of unknown HIV status.

Dominguez KL et al. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection-drug use, or
other nonoccupational exposure to HIV United States, 2016. MMWR Morb Mortal Wkly Rep 2016 May 6; 65:458.
(http://dx.doi.org/10.15585/mmwr.mm6517a5)

Kevin Ard, MD, MPH, is Assistant in Medicine, Infectious Disease Division at Massachusetts General Hospital;
and Instructor in Medicine, Harvard Medical School, Boston.

Rajesh T. Gandhi, MD, is Associate Professor of Medicine and Director, HIV Clinical Services and Education,
Harvard Medical School; site leader, Massachusetts General Hospital AIDS Clinical Trials Site, Harvard/Boston
Medical Center/Miriam AIDS Clinical Trials Unit; and Director, Harvard University Center for AIDS Research
(CFAR) Clinical Core.

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Guidelines for Acne Care and Management

Craig A. Elmets, MD, reviewing Zaenglein AL et al. J Am Acad Dermatol 2016 Feb 15.

Updated guidance for managing this common condition

Sponsoring Organization: The American Academy of Dermatology

Target Audience: Primary care clinicians, pediatricians, dermatologists

Background
Acne affects an estimated 50 million individuals in the United States with a cost that exceeds $3 billion/year.
Although the mortality from the disease is virtually nonexistent, it can cause extensive scarring and inflict significant
emotional damage, especially on adolescents. The American Academy of Dermatology has revised its guidelines for
the management of this disease.

Key Points
Microbial testing is not usually recommended unless there is concern for gram-negative folliculitis. Endocrino-
logical evaluation, including free and total testosterone, dehydroepiandrosterone sulfate, androstenedione, lutein-
izing hormone, and follicle-stimulating hormone, is appropriate when there is evidence of hyperandrogenism
(irregular menses, hirsutism, androgenetic alopecia, polycystic ovaries, or truncal obesity).
Topical retinoids are an essential element of topical acne therapy; they are comedolytic and have an anti-
inflammatory effect. Topical antibiotics when used together with benzoyl peroxide increase efficacy and reduce
the likelihood of bacterial antibiotic resistance. Topical antibiotics alone are not recommended. Other effective
topical formulations include azelaic acid, dapsone, niacinamide, and salicylic acid. There is no evidence that
topical zinc is effective.
Oral antibiotics (tetracycline family, macrolides, trimethoprim/sulfamethoxazole, penicillins, cephalosporins)
are indicated for moderate-to-severe acne. They should be prescribed in combination with topical retinoids and
benzoyl peroxide, and monotherapy is strongly discouraged. In most patients, they should be given for no longer
than 3 months.
Four oral contraceptive pills are FDA approved for acne therapy: ethinyl estradiol/norgestimate, ethinyl estradiol/
norethindrone acetate/ferrous fumarate, ethinyl estradiol/drospirenone, and ethinyl estradiol/drospirenone/
levomefolate. They mediate and inhibit androgen activities and have been found to improve both comedonal
and inflammatory acne. The only antibiotics that limit the efficacy of oral contraceptive pills are rifampin and
griseofulvin; the tetracycline class has not been shown to limit such efficacy.
Oral isotretinoin is indicated for severe acne, treatment-resistant or relapsing moderate acne, or acne producing
scarring or having substantial psychological effect. Most formulations should be taken at meal time. It should be
given until a goal of 120150 mg/kg has been reached. Laboratory monitoring of lipids and liver function should
be conducted regularly; no evidence shows complete blood counts are necessary. Although isotretinoin was
thought to cause flares in inflammatory bowel disease, recent studies do not support this.
Photodynamic therapy, chemical peels, and comedonal removal are supported by some evidence. Intralesional
injection of corticosteroid solutions is common for acne nodules.
High glycemic diets and milk consumption, particularly skim milk, have been associated with acne and its
aggravation.

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COMMENT
Since the American Academy of Dermatology last published guidelines for acne, a number of new observations
have been made. This comprehensive update makes evidence-based recommendations.

Zaenglein AL et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016 Feb 15; [e-pub].
(http://dx.doi.org/10.1016/j.jaad.2015.12.037)

Craig A. Elmets, MD, is Chairman, Department of Dermatology and Director, Skin Diseases Research Center,
University of Alabama School of Medicine, Birmingham.

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