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Dietary and Pharmacologic Management to Prevent Recurrent Nephrolithiasis in Adults

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Nonsurgical Management of Urinary Incontinence in Women

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ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.

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A 56-year-old woman is admitted to the hospital for an exacerbation of chronic obstructive pulmonary disease that developed over the past 5 days. Because of her pulmonary symptoms, she has not been eating well but has continued taking her medications. Medical history is also remarkable for atrial fibrillation and hypertension. Medications are hydrochlorothiazide, atenolol, albuterol and ipratropium metered-dose inhalers, prednisone, and warfarin.

On physical examination, temperature is 37.2°C (99.0°F), blood pressure is 150/90 mm Hg, pulse rate is 112/min, and respiration rate is 24/min. Oxygen saturation breathing ambient air is 92%. No bruising or petechia is noted. The remainder of the physical examination is unremarkable.

Laboratory studies on admission are significant for an INR of 4.0.


Which of the following is the most appropriate management of this patient?

Warfarin should be withheld without administration of plasma or factor concentrates for reversal of anticoagulation. Excess anticoagulation is common in patients taking warfarin. The need for reversal is based on the degree of elevation of the INR and whether bleeding is present. For INR elevations of 5.0 or less, simply withholding warfarin and resuming therapy at a lower dose after the INR has returned to the desired range is adequate. Higher INR elevations in patients who are not bleeding may be treated with vitamin K in addition to withholding warfarin. Active reversal of anticoagulation using either plasma or factor concentrates is indicated only in situations in which emergent treatment is required, such as major bleeding, intracranial hemorrhage, or anticipated emergent surgery. This particular recommendation is among the five items on the American Society of Hematology's Choosing Wisely list. Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation that asks specialty and subspecialty societies to identify tests, treatments, and procedures that have little evidence of support for their use and may be costly or even harmful to patients. Choosing Wisely is an effort to create mindfulness of the potential benefits and harms of common medical interventions and is consistent with the American College of Physician's High Value Care initiative that seeks to help physicians provide the best possible care to their patients and reduce unnecessary costs to the health care system.

Key Point

  • Recommendations from the Choosing Wisely campaign affirm that reversal of vitamin K antagonists with plasma or factor concentrates is not necessary in the absence of significant bleeding, intracranial hemorrhage, or impending emergency surgery.
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