SPRINT: Celebrating Benefits for Older Patients
SOURCE: Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥ 75 years: A randomized clinical trial. JAMA 2016;315:2673-2682.
Hypertension experts and generalists alike consider the Systolic Blood Pressure Intervention Trial (SPRINT) a game changer. Despite the advice from Eighth Joint National Committee that lowering blood pressure to < 140/90 mmHg was sufficient for most non-senior adults, the question of whether lower is better was never believed to have been adequately clarified. SPRINT determined that aiming for a systolic blood pressure of < 120 mmHg provided significant reductions in cardiovascular and all-cause mortality compared to “traditional” blood pressure goals (< 140 mmHg systolic blood pressure) in hypertensive non-diabetic adults. SPRINT also was large enough (n = 9,361) and included a sufficient number of patients > 75 years of age (n = 2,636) to make meaningful commentary about benefits in that specific age demographic.
After a median of 3.14 years follow-up in patients > 75 years of age (mean age = 80 years), major adverse cardiovascular events fell by approximately one-third in the intensively treated group, as was all-cause mortality, without incurring excess serious adverse events.
SPRINT is not the first clinical trial to confirm benefits of treating hypertension in super-seniors. The Hypertension in the Very Elderly Trial (HYVET; mean age = 83 years) ended early due to the important mortality reductions observed in treated seniors attributable to blood pressure control. Using available knowledge, age should not be considered a barrier to seeking good blood pressure control.
Updates on the USPSTF Colorectal Cancer Screening Recommendations
SOURCE: US Preventive Services Task Force. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA 2016;315:2564-2575.
In accordance with previous recommendations, the United States Preventive Services Task Force still endorses colorectal cancer (CRC) screening in adults 50-75 years of age. For patients > 75 years of age, the decision has to be individualized, especially for those who have not received screening as recommended earlier in life.
Because of a lack of studies demonstrating particular advantage of one CRC screening method over another in head-to-head comparison trials, each of the recommended methods has to be evaluated on its own merits and tolerability. Taking that into consideration, it appears that of the nine CRC screening methods evaluated (including flexible sigmoidoscopy, fecal immunochemical stool testing, colonoscopy, CT colonography, etc.), each provides a substantial increase in life expectancy, with a very small margin of greater efficacy for colonoscopy.
Any harms related to CRC screening generally are associated with colonoscopy, whether it is used as the primary screening method or in follow-up of another screening method. Overall, either colonic perforation or major intestinal bleeding occurs in approximately 1/1,000 colonoscopies. In conjunction with previous American Cancer Society recommendations, rather than focus on particular advantages of one screening method vs. another (since all interventions improve outcomes, and demonstrated differences appear to be modest), it is more important to identify a screening method the patient will endorse than debate any between-method differences in efficacy.
Predicting Opioid Abuse and Dependence
SOURCE: Ciesielski T, Iyengar R, Bothra A, et al. A tool to assess risk of de novo opioid abuse or dependence. Am J Med 2016;129:699-705.
In an era in which opioid overdose has outstripped auto accidents as a cause of mortality in adults ≤ 45 years of age in many states, it is critical to learn how to better identify patients at risk of opioid addiction, abuse, and dependence. There already are several screening tools for opioid misuse available to clinicians such as the Opioid Risk Tool and the Screener and Opioid Assessor for Patients in Pain; however, patients who are willing to be untruthful and hide their risk factors render such tools meaningless.
Ciesielski et al retrospectively studied a large sample from a health insurance database (n = 649,851), from which the authors identified 2,067 cases of opioid abuse or dependence. Predictors for abuse or dependence include younger age, chronic opioid use, psychiatric history, abuse of nonopioid substances, alcohol abuse, smoking, use of high morphine doses, receiving prescriptions from more than one source or pharmacy, male gender, and South or Midwest residence.
Most of the risk factors for abuse/dependence identified through this database have been identified and used by earlier established risk screeners. Because this was a retrospective analysis, whether utilizing a risk stratification tool comprised of all 12 risk factors noted in this population would improve risk prediction remains to be determined.