ACP, AAFP release new guideline for treatment of non-low back pain from musculoskeletal injuries

Below please find summaries of new articles that will be published in the next issue of

Annals of Internal Medicine

. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.

1. ACP, AAFP release new guideline for treatment of non-low back pain from musculoskeletal injuries in adults

Recommends topical NSAIDs as first-line therapy, suggests against use of opioids

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The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) today released a new clinical guideline recommending that physicians treat acute pain from non-low back musculoskeletal injuries with topical NSAIDs, with or without menthol gel, as first-line therapy. The new, evidence-based, joint guideline is published in

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The guideline also suggests that oral NSAIDS, acetaminophen, specific acupressure, or transcutaneous nerve stimulation are effective treatments and suggests against using opioids, including tramadol, except in cases of severe injury or intolerance of first-line therapies. Non-Pharmacological and Pharmacological Management of Acute Pain from Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline from the American College of Physicians and American Academy of Family Physicians was developed based on the best available evidence of the benefits and harms of managing this condition in the outpatient setting. This guideline focused on non-low back pain since low back pain has been specifically addressed in other guidelines.

Musculoskeletal injuries, including ankle, neck, and knee injuries, are common and most frequently treated in outpatient settings. In 2010, they accounted for more than 65 million health care visits in the United States, and, of injuries that were treated in a physician’s office, four out of five were musculoskeletal. The estimated annual cost of treating musculoskeletal injuries was $176.1 billion in 2010.

The ACP and AAFP are two of the largest physician organizations in the United States representing primary care doctors. Their combined membership – nearly 300,000 – including internal medicine physicians (internists) and family physicians, treat a large majority of patients in the United States who experience pain.

In the guideline, the ACP and AAFP suggest against prescribing opioids for patients with acute pain from non-low back, musculoskeletal injuries. This includes tramadol, except in cases of severe injury or intolerance of first-line therapies. Opioids are associated with the risk of long-term addiction and overdose. Rather, the guideline recommends topical NSAIDs, with or without menthol gel, as the first-line therapy in patients with acute pain from non-low back, musculoskeletal injuries. Evidence has shown that topical NSAIDs were among the most effective for pain reduction, physical function, treatment satisfaction, and symptom relief and were not associated with any significant harms. The guideline suggests several other treatment options, including oral NSAIDs to reduce or relieve symptoms including pain or acetaminophen to reduce pain, in addition to specific acupressure and transcutaneous electrical nerve stimulation to reduce pain.

Media contacts: For an embargoed PDF or to speak with someone from ACP, please contact Andrew Hachadorian at

[email protected]

or 215-351-2514. To speak with someone from the AAFP, please contact Janelle Davis at

[email protected]

or 913- 912-0377.

2. Bariatric surgery associated with reduced risk for dying over the long-term, especially for older patients

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A study of more than 26,000 patients found that bariatric surgery is associated with a lower risk for dying over the long-term, especially for heavier patients and those who have weight loss surgery at older ages. The results are published in

Annals of Internal Medicine

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Researchers from McMaster University and St. Joseph’s Healthcare Hamilton, Ontario, Canada studied more than 13,000 adults with moderate to severe obesity who had weight loss surgery and a matched cohort of more than 13,000 patients who were eligible for surgery but did not have it from 2010 to 2016 in Ontario to compare the risk for dying over the long term between the two groups. They also examined whether the age, gender, and BMI at the time of surgery had any impact on survival.

After a median follow-up of almost 5 years, the researchers found that the overall mortality rate was 1.4 percent in the surgery group and 2.5 percent in the nonsurgery group, with a lower adjusted hazard ratio of all-cause mortality (HR, 0.68 [95% CI, 0.57 to 0.81]). The difference in mortality risk was substantial among older adults and those who were more obese when they had bariatric surgery. After measurable differences between patients who had surgery and those who didn’t were accounted for, patients aged 55 years or older had a 48 percent lower risk for dying than matched patients who didn’t have surgery. Meanwhile, men and women derived essentially equal benefits. According to the researchers, their study provides one of the most complete pictures of the association between bariatric surgery and mortality by delineating the specific effects among several important patient subgroups.

Media contacts: For an embargoed PDF please contact Lauren Evans at

[email protected]

. The lead author, Aristithes Doumouras, MD, MPH, can be reached directly at

[email protected]

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3. Bariatric Surgery may help patients with mild to moderate obesity and hypertension reduce the need for medication

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Roux-en-Y gastric bypass (RYGB), a type of weight loss surgery, may help patients with mild to moderate obesity (defined as a body mass index between 30 and 40 kg/m2) and hypertension reduce the need to for medication. Weight loss surgery is not currently recommended for patients with mild obesity, but these findings suggest that it could be beneficial for some patients. Findings from a randomized trial are published in

Annals of Internal Medicine

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Researchers from HCor Research Institute, São Paulo, Brazil, studied 100 men and women aged 18 to 65 years with mild to moderate obesity and hypertension to determine the effectiveness of bariatric surgery and lifestyle counseling in reducing the need for blood pressure medication. All of the participants took at least two hypertension medications at the start of the trial. Participants were randomly assigned to receive either weight loss surgery and lifestyle counseling or lifestyle counseling without surgery. Both groups also received standard medical treatment for hypertension. Participants received their assigned treatment and blood pressure medication use, blood pressure readings, and other laboratory markers were monitored for 3 years.

The researchers found that participants who were assigned to receive weight loss surgery reduced the number of blood pressure medications they were taking. The typical participant in the weight loss surgery group took one blood pressure medication after 3 years, whereas the typical participant in the nonsurgery group took three blood pressure medications. Blood pressure control was similar in the two groups, but 35 percent of patients who had bariatric surgery were free of medication with a controlled blood pressure (<140/90 mmHg). According to the researchers, bariatric surgery may be an attractive option for patients with difficult-to-treat hypertension or for whom nonadherence to medical therapy and its related consequences are major concerns.

Media contacts: For an embargoed PDF please contact Lauren Evans at

[email protected]

. The lead author, Carlos A. Schiavon, MD, can be reached through Luna Aghata at

[email protected]

or +55 11 99290 7988.

4. Fecal transplant effectively treats a case of auto-brewery syndrome

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Clinicians who have patients with gut fermentation syndrome should consider treatment with fecal microbiota transplantation, especially if more traditional therapy has failed. Researchers from University Hospital Ghent, Ghent, Belgium describe the first case report showing efficacy of this method for treating the rare syndrome. The case report is published in

Annals of Internal Medicine

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Gut fermentation syndrome, also known as auto-brewery syndrome, is a rare condition in which the body produces ethanol in the gut after carbohydrate-rich meals. The condition is problematic because it leads to elevated blood alcohol levels, a feeling of drunkenness, variably disturbed liver function, and other indications of ethanol intoxication.

The authors describe the case of a 47-year-old man who had intermittent episodes of feeling drunk during the previous 2 months, even when he had not consumed any alcohol. After a series of tests ruled out other conditions, the clinicians suspected gut fermentation syndrome. The patient was prescribed a low-carbohydrate diet and antimycotic drugs, but continued to show signs of alcohol intoxication despite not consuming any. The clinicians proposed a fecal microbiota transplantation, after which symptoms of ethanol intoxication disappeared immediately. The man regained his normal carbohydrate-rich diet and reported drinking on occasion. This successful outcome lasted at least until the latest follow-up of 34 months. The researchers suggest that these findings present a new option for other patients with difficult-to-treat gut fermentation syndrome.

Media contacts: For an embargoed PDF please contact Lauren Evans at

[email protected]

. The lead author, Danny De Looze, MD, PhD, can be reached directly at

[email protected]

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Also in this issue:

Cough: Burst Steroids or No Steroids?

Geno J. Merli, MD, Howard H. Weitz, MD

Annals Consult Guys

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W19-0041

Inpatient Notes: Realizing the Promises of Hospital Electronic Order Sets

Ron C. Li, MD, and Jonathan H. Chen, MD, PhD

Annals for Hospitalists

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M20-5164

Diagnosing SARS-CoV-2 Infection: Symptoms or No Symptoms

Robert M. Centor, MD

Annals On Call

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A19-0036

Academic Medicine Monsters

Tigges

Annals Graphic Medicine

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G19-0084

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