Irritable Bowel Syndrome

This issue provides a clinical overview of irritable bowel syndrome, focusing on diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

Annals for Educators - 3 October 2017

Annals for Educators - 1 August 2017

Allopurinol Initiation and All-Cause Mortality Among Patients With Gout and Concurrent Chronic Kidney Disease: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 175, No 4

Background: Two recent randomized clinical trials of escalating doses of allopurinol for the progression of chronic kidney disease (CKD) reported no benefits but potentially increased risk for death. Whether the risk could occur in patients with gout and concurrent CKD remains unknown. Objective: To examine the relation of allopurinol initiation, allopurinol dose escalation, and achieving target serum urate (SU) level after allopurinol initiation to all-cause mortality in patients with both gout and CKD. Design: Cohort study. Setting: The Health Improvement Network U.K. primary care database (2000 to 2019). Participants: Patients aged 40 years or older who had gout and concurrent moderate-to-severe CKD. Measurements: The association between allopurinol initiation and all-cause mortality over 5-year follow-up in propensity score (PS)–matched cohorts was examined. Analysis of hypothetical trials were emulated: achieving target SU level (<0.36 mmol/L) versus not achieving target SU level and dose escalation versus no dose escalation for mortality over 5-year follow-up in allopurinol initiators. Results: Mortality was 4.9 and 5.8 per 100 person-years in 5277 allopurinol initiators and 5277 PS-matched noninitiators, respectively (hazard ratio [HR], 0.85 [95% CI, 0.77 to 0.93]). In the target trial emulation analysis, the HR of mortality for the achieving target SU level group compared with the not achieving target SU level group was 0.87 (CI, 0.75 to 1.01); the HR of mortality for allopurinol in the dose escalation group versus the no dose escalation group was 0.88 (CI, 0.73 to 1.07). Limitation: Residual confounding cannot be ruled out. Conclusion: In this population-based data, neither allopurinol initiation, nor achieving target SU level with allopurinol, nor allopurinol dose escalation was associated with increased mortality in patients with gout and concurrent CKD. Primary Funding Source: Project Program of National Clinical Research Center for Geriatric Disorders.

Hearing From the Silent Epidemic

Update in Rheumatology: Evidence Published in 2015

How Would You Manage This Patient With Nonvariceal Upper Gastrointestinal Bleeding?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 174, No 6

Nonvariceal upper gastrointestinal bleeding is common, morbid, and potentially fatal. Cornerstones of inpatient management include fluid resuscitation; blood transfusion; endoscopy; and initiation of proton-pump inhibitor therapy, which continues in an individualized manner based on risk factors for recurrent bleeding in the outpatient setting. The International Consensus Group released guidelines on the management of nonvariceal upper gastrointestinal bleeding in 2019. These guidelines provide a helpful, evidence-based roadmap for management of gastrointestinal bleeding but leave certain management details to the discretion of the treating physician. Here, 2 gastroenterologists consider the care of a patient with nonvariceal upper gastrointestinal bleeding from a peptic ulcer, specifically debating approaches to blood transfusion and endoscopy timing in the hospital, as well as the recommended duration of proton-pump inhibitor therapy after discharge.

Should You Recommend Cannabinoids for This Patient With Painful Neuropathy?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 174, No 2

Cannabis includes 140 active cannabinoid compounds, the most important of which are tetrahydrocannabinol and cannabidiol (CBD). Tetrahydrocannabinol is primarily responsible for the intoxicating effects of cannabis; CBD has potential therapeutic effects, including reduction in chronic pain. Recent legislative changes have resulted in the legal availability of cannabinoids in all 50 states, as well as a marked increase in patients' interest in their use. Despite an abundance of data, albeit of varied quality, clinicians may feel poorly prepared to counsel patients seeking advice on the suitability of CBD products for various indications, particularly chronic neuropathic pain. In 2018, on the basis of a systematic review of the literature, a Canadian Evidence Review Group published a guideline with recommendations for clinicians on prescribing cannabinoids in primary care practice. The overall quality of evidence was low to very low. In a meta-analysis of 15 randomized trials of medical cannabis for treating chronic pain, 39% of patients achieved at least a 30% reduction in pain. The corresponding value for placebo-treated patients was 30%; the number needed to treat was 11. More evidence exists for neuropathic pain than for other types of noncancer pain. Here, a general internist with a focus on addiction medicine and an addiction psychiatrist discuss how they would apply the literature to make recommendations for a patient with painful diabetic neuropathy, including counseling on both potential benefits and harms.

Global Hemophilia Care: Data for Action

Integrating Methadone Services Into Primary Care in Ukraine: Two-Year Outcomes From a Randomized Trial

Background: Opioid use disorder (OUD) drives high morbidity and mortality, but access to opioid agonist therapy (OAT) is limited in low- and middle-income countries. Integrating OAT into primary care may expand access and improve comorbidity management, although provider discomfort remains a barrier. Objective: To compare health care use among persons with OUD receiving methadone in specialty clinics versus primary care centers in Ukraine (January 2018 to December 2023). Design: Two-group randomized controlled trial with 2:1 allocation to intervention and control. (ClinicalTrials.gov: NCT04927091) Setting: Thirteen cities in Ukraine: Cherkasy, Dnipro, Kramatorsk, Kropyvnytskyi, Kryvyi Rih, Kyiv, Lviv, Mariupol, Mykolaiv, Odesa, Rivne, Sloviansk, and Zhytomyr. Participants: A total of 1459 adults with OUD (950 intervention, 509 control) initiating or receiving methadone. Intervention: Methadone delivered in primary care aided with telementoring, an Extension for Community Healthcare Outcomes–like model that is adapted to the Ukraine context, versus standard specialty clinic care. Measurements: Primary outcome: difference in composite quality health indicator (QHI) scores between groups at 24 months, representing access to 17 guideline-concordant services (9 primary care and 8 specialty care) received, assessed through surveys and ranging from 0 to 100. Secondary outcomes: domain-specific QHI scores and methadone treatment indicators. Results: Participants in primary care settings achieved higher composite QHI scores than those in specialty clinics, with a mean difference of 9.1 percentage points (95% CI, 6.9 to 11.2 percentage points) at 24 months. Results were similar for primary care QHI (12.3 percentage points [CI, 9.0 to 15.6 percentage points]) and specialty care QHI (5.2 percentage points [CI, 0.2 to 10.3 percentage points]). Methadone retention among new patients at 24 months was 67.2% in primary care versus 64.7% in specialty clinics. Limitations: Quality health indicators reflect health care use rather than health outcomes. Quality health indicators were equally weighted despite differing clinical significance. Conclusion: Integrating methadone treatment into primary care settings improves adherence to guideline-concordant health care without compromising methadone retention and treatment quality. Primary Funding Source: National Institute on Drug Abuse.