Orthostatic Changes in BP Among Hypertensives

SOURCE: Townsend RR, Chang TI, Cohen DL, et al. Orthostatic changes in systolic blood pressure among SPRINT participants at baseline. J Am Soc Hypertens 2016;10:847-856.

Upon standing from a sitting or supine position, compensatory changes in heart rate and vascular tone maintain both systolic blood pressure and diastolic blood pressure fairly consistently. Postural changes in blood pressure of more than a 20 mmHg drop in systolic blood pressure or a 10 mmHg drop in diastolic blood pressure (or both) within three minutes of standing are defined as orthostatic hypotension, although only a minority of individuals with measurable orthostatic hypotension experience any clinical manifestations such as dizziness, lightheadedness, or falls. On the other hand, orthostatic hypotension has been associated with worsened cardiovascular outcomes, even when asymptomatic.

Townsend et al reported on baseline data from the SPRINT trial, which collected data on orthostatic blood pressure changes in 8,662 participants at baseline. Overall, 7% (n = 634) of enrollees demonstrated orthostatic hypotension, although the element by which they met the diagnostic criteria for orthostatic hypotension varied: 294 subjects met systolic blood pressure criteria, 227 met diastolic blood pressure criteria, and 113 met both.

No one has suggested that asymptomatic orthostatic hypotension requires treatment. On the other hand, symptomatic orthostatic hypotension places patients at risk for falls with subsequent consequences such as hip fractures, leading to increased mortality.

Because patients may not always be forthcoming about symptoms referable to orthostatic hypotension, more routine measurement of orthostatic blood pressure changes in hypertensive patients may help identify those at risk.

Atopic Dermatitis Associated with Smoking

SOURCE: Kantor R, Kim A, Thyssen JP, Silverberg JI. Association of atopic dermatitis with smoking: A systematic review and meta-analysis. J Am Acad Dermatol 2016;75:1119-1125.

Atopic dermatitis is a chronic, often lifelong disorder affecting people of all ages. In addition to troublesome cosmetic effects, the pruritus of atopic dermatitis has been demonstrated to be extremely disruptive to sleep in children, and often requires systemic antihistamine treatment for control.

A lifelong requirement for periodic treatment with topical steroids and/or topical calcineurin inhibitors (e.g., pimecrolimus, tacrolimus) is not uncommon for mild-to-moderate sufferers. Severe atopic dermatitis may require systemic treatments, including immune modifiers such as cyclosporine.

Smoking has been demonstrated to be associated with atopic dermatitis. The association was found to be statistically significant in children and adults. Of particular concern, smoking in the home was associated with atopic dermatitis in passively exposed children.

There is some predictability within families with an atopic diathesis (i.e., common presence of atopic disorders such as asthma, allergic rhinitis, and eczema) that children are more likely to develop atopic dermatitis. In addition to the many other good reasons to stop smoking, we can add an increased incidence of atopic dermatitis.

An Action Plan for Eczema

SOURCE: Sauder MB, McEvoy A, Ramien ML. Prescribing success: Developing an integrated prescription and eczema action plan for atopic dermatitis. J Am Acad Dermatol 2016;75:1281-1283.

Many clinicians may be familiar with the concept of an action plan in reference to asthma management. National guidelines suggest that providing patients with a stratified plan to address intensification of their asthma treatment regimen based on symptoms and measurements of peak flow rates may enhance control.

Recently, similar advice has been offered — and supported by favorable outcomes from a randomized, controlled trial — for patients suffering from atopic dermatitis.

The proposed atopic dermatitis action plan features three ‘zones’ (green, yellow, and red), similar to asthma action plans. In the green zone, eczema is ‘under control,’ and patients should continue their daily moisturizer, possibly with use of their topical steroid and/or topical calcineurin inhibitor (e.g., tacrolimus, pimecrolimus). The yellow zone indicates worsening eczema, which calls for increased dosing of steroids or calcineurins. The red zone indicates uncontrolled eczema, which indicates that clinician contact is appropriate and a prescription for stronger corticosteroids is needed.

At this point, action plans for eczema are a fairly new concept. It is anticipated that such action plans will evolve as we learn more about their efficacy in enhancing patient self-care and timely consultations.