Nalbuphine may help manage opioid-induced urine retention

1. Nalbuphine may help manage opioid-induced urine retention

Abstract: http://annals.org/aim/article/doi/10.7326/L18-0387

URLs go live when the embargo lifts

Nalbuphine may help to manage opioid-induced urine retention. Findings from a brief case report are published in Annals of Internal Medicine.

Urine retention is common in the hospital setting and is sometimes caused by the use of opioids. Once opioid-induced urine retention develops, resolving it without interfering with pain control can be problematic.

Clinicians from Southern Illinois University School of Medicine saw a patient with a history of alcoholic cirrhosis who was hospitalized for right-sided abdominal pain, and diagnosed with portal vein thrombosis and hepatocellular cancer. The patient was treated with hydromorphone for pain and quickly developed urine retention. The patient did not respond to α-1 blockers and found a catheter to be effective but inconvenient. The clinicians gave the patient a dose of intravenous nalbuphine, an opioid used to treat moderate to severe pain that has a different mechanism of action than other opioids. The patient responded well to the medication and was able to urinate within the first 6 hours.

According to the authors, these findings suggest that clinicians should consider offering nalbuphine to patients with opioid-induced urine retention that does not respond to α-1 blockers who prefer not to continue using bladder catheterization.

Media contact: For an embargoed PDF, please contact Lauren Evans at [email protected] To interview the lead author, Abdisamad M. Ibrahim, MD, please contact him directly at [email protected]

2. Cost a key consideration of WHO guidelines for diabetes treatment intensification

Recently published guidelines make recommendations on use of medicines for treatment intensification of type 2 diabetes and type of insulin in type 1 and type 2 diabetes

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1149

Editorial: http://annals.org/aim/article/doi/10.7326/M18-1148

URLs go live when the embargo lifts

The World Health Organization (WHO) recently issued guidelines on the selection of medicines for treatment intensification in patients with type 2 diabetes and on the use of insulin in patients with type 1 or 2 diabetes. A synopsis of the guidelines is published in Annals of Internal Medicine.

Type 2 diabetes is highly prevalent in most settings, and the increase in prevalence has been greatest in low- and middle-income countries in the past few decades. WHO develops guidelines for settings with limited health system resources where the health care budget can be quickly exhausted with widespread use of expensive brand-name medications. WHO guidelines also apply to high-income countries where patients with limited resources need evidence-based care that takes into account costs and value.

WHO made the following five recommendations:

  • Give a sulfonylurea to patients with type 2 diabetes who do not achieve glycemic control with metformin alone or who have contraindications to metformin.
  • Introduce human insulin treatment to patients with type 2 diabetes who do not achieve glycemic control with metformin and/or a sulfonylurea.
  • If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor, or a thiazolidinedione (TZD) may be added.
  • Use human insulin to manage blood glucose in adults with type 1 diabetes and in adults with type 2 diabetes for whom insulin is indicated.
  • Consider long-acting insulin analogues to manage blood glucose in adults with type 1 or type 2 diabetes who have frequent severe hypoglycemia with human insulin.

The authors of an accompanying commentary by members of the High Value Care Committee of the American College of Physicians (ACP) consider the nuances of clinical decision-making in the face of limited evidence and limited resources. They also compare key differences between ACP and WHO guidelines. The authors suggest that the decision to name sulfonylureas as the single best second-line agent for type 2 diabetes largely reflects the prioritization of cost and the recognition that WHO guidelines must apply to low-resource settings. ACP also acknowledges cost in its guideline, but places a priority on shared decision making between physicians and patients and on quality of life. ACP's guideline recommends that clinicians and patients discuss benefits, adverse effects, and costs when considering second-line therapy options, including sulfonylureas, which present a higher risk for hypoglycemia, and the newer agents, which may have a more favorable side-effects profile but are more expensive.

Media contact: For an embargoed PDF or to interview the editorialist from ACP's High Value Care Committee, please contact Steve Majewski at [email protected]

3. Patient says ALS took away control over his body; court ruling took away control over his life

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1719

URLs go live when the embargo lifts

Michael Danielson (photo available), a terminally ill patient in San Diego, says that ALS took away control over his body and then the court's decision to overturn California's End of Life Option Act took away control over his life. Danielson's essay is published in Annals of Internal Medicine.

When Danielson was diagnosed with ALS, he was pragmatic about his prognosis. Knowing that the disease would eventually kill him, he told his friends and family that when the time came, he would end his life on his own terms. At the time, California was one of a handful of states that allowed physicians to legally assist patients in dying. The law was written so that a person's underlying illness and not "medical aid in dying" would be recorded as the cause of death on the death certificate. In Danielson's case, it would be ALS. This is a very important distinction for insurance companies, families, and patients going through a terminal illness.

On May 24, California's End of Life Option Act was overturned, a decision that has caused Danielson a great deal of anxiety knowing how much he will suffer. As for the Hippocratic oath doctors take that begins, 'First, do no harm,' Danielson says that doctors are doing more harm by keeping terminally ill patients alive needlessly than by allowing them to take control and have a dignified passing of their choice.

Media contact: For an embargoed PDF, please contact Lauren Evans at [email protected] For an interview with the patient, please contact Sara Gianella Weibel at [email protected] To speak with Dr. David Grube from Compassion and Choices, please contact him directly at [email protected]

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Also new in this issue:

PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation

Andrea C. Tricco, PhD, MSc; Erin Lillie, MSc; Wasifa Zarin, MPH; Kelly K. O'Brien, PhD, BScPT; Heather Colquhoun, PhD; Danielle Levac, PhD, MSc, BScPT; David Moher, PhD, MSc; Micah D.J. Peters, PhD, MA(Q); Tanya Horsley, PhD; Laura Weeks, PhD; Susanne Hempel, PhD; Elie A. Akl, MD, PhD, MPH; Christine Chang, MD, MPH; Jessie McGowan, PhD; Lesley Stewart, PhD, MSc; Lisa Hartling, PhD, MSc, BScPT

Research and Reporting Methods

Abstract: http://annals.org/aim/article/doi/10.7326/M18-0850

Scoping Reviews and Systematic Reviews: Is It an Either/Or Question?

Stephanie Chang, MD, MPH

Editorial

Abstract: http://annals.org/aim/article/doi/10.7326/M18-2205

Media Contact

Angela Collom
[email protected]
215-351-2653
@ACPinternists

http://www.acponline.org

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