Practice Changing UpDates

INTRODUCTION — This section highlights selected specific new recommendations and/or updates that we anticipate may change usual clinical practice. Practice Changing UpDates focus on changes that may have significant and broad impact on practice, and therefore do not represent all updates that affect practice. These Practice Changing UpDates, reflecting important changes to UpToDate over the past year, are presented chronologically, and are discussed in greater detail in the identified topic reviews.

PSYCHIATRY (December 2022, Modified July 2023)

Screening for anxiety in children and adults

●We suggest screening for anxiety disorders in individuals between age 8 and 65 years (Grade 2C).

Anxiety disorders are common but underrecognized conditions and may cause chronic distress and impaired functioning throughout the lifespan. The United States Preventive Services Task Force now recommends screening for anxiety in all individuals ages 8 to 65 years, including pregnant and postpartum persons [1,2]. These new recommendations are supported by systematic reviews and meta-analyses in both children and adults, documenting that screening tools can accurately identify anxiety disorders and that treatment results in moderate benefits in reducing anxiety and improving disease remission [3,4]. Major harms were not identified. Evidence was insufficient to demonstrate benefits and harms in individuals <8 or >65 years, although screening may also be appropriate in these individuals. Our approach is consistent with these recommendations. (See "Anxiety disorders in children and adolescents: Assessment and diagnosis", section on 'Screening' and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Screening'.)

INFECTIOUS DISEASES (April 2023)

Bivalent COVID-19 mRNA vaccine recommendations

●All individuals aged six years and older should receive a bivalent mRNA COVID-19 vaccine, if they have not already received one. Certain individuals have the option for additional bivalent vaccine doses: For individuals with moderately to severely immunocompromising conditions (table 1) who had already been vaccinated with monovalent vaccines and subsequently received one bivalent vaccine dose, we suggest an additional bivalent vaccine dose, given at least two months after the first (Grade 2C). We individualize the decision to offer additional bivalent vaccine doses after the second based on exposure risk and severity of immunosuppression. For adults aged 65 and older who have already received a bivalent vaccine dose and do not have a moderately to severely immunocompromising condition, we base the decision to give a second bivalent vaccine on the individual risk for severe COVID-19, history of SARS-CoV-2, exposure risk, and patient preference.

The US Food and Drug Administration and Centers for Disease Control and Prevention have updated COVID-19 vaccine authorizations and recommendations [5-7]. All individuals aged six years and older should receive at least one bivalent mRNA vaccine dose if they have not already. For most immunocompetent people, a single bivalent vaccine dose to boost pre-existing SARS-CoV-2 immunity (from prior vaccination or infection) is expected to be sufficient (algorithm 1). Individuals who have moderately to severely immunocompromising conditions (table 1) and adults ≥65 years old have the option to receive a second bivalent vaccine dose to maximize protection in case of waning immunity. For children six months to five years old, the number of bivalent vaccine doses depends on their vaccination history and whether they are receiving the Moderna or Pfizer COVID-19 vaccine (algorithm 2). Monovalent mRNA vaccines are no longer recommended. (See "COVID-19: Vaccines".)

INFECTIOUS DISEASES; PRIMARY CARE (ADULT); FAMILY MEDICINE AND GENERAL PRACTICE (April 2023)

Expanded recommendations for hepatitis B virus screening in adults

●For most individuals without risk factors for hepatitis B virus (HBV), we suggest one-time HBV screening for those ≥18 years of age (Grade 2C). For adults at increased risk for acquiring HBV (table 1), we recommend HBV screening (Grade 1B).

Screening for hepatitis B virus (HBV) in adults has traditionally been recommended for those with risk factors (table 2). In March 2023, the United States Centers for Disease Control and Prevention expanded their recommendations to include universal screening for persons ≥18 years of age at least once during their lifetime, regardless of risk [8]. The rationale is the prevalence of chronic HBV infection in the general population (0.4 percent), the low vaccination rates in adults, and the harms of missed infection such as fulminant hepatitis and liver cancer. Testing should include hepatitis B surface antigen, hepatitis B surface antibody (anti-HB), and total hepatitis B core antibody. We support universal screening; however, screening is generally not needed if an HBV vaccine series has been completed and there is serologic evidence of immunity (anti-HBs ≥10 milli-international units/mL). (See "Hepatitis B virus: Screening and diagnosis in adults", section on 'Individuals without known risk for HBV infection'.)

ALLERGY AND IMMUNOLOGY (March 2023, Modified April 2023)

Cow's milk elimination alone for eosinophilic esophagitis

●In patients with eosinophilic esophagitis who opt for a dietary approach to treatment, we suggest elimination of cow's milk (in all its forms) and cross-reacting mammalian milk rather than simultaneous removal of multiple foods (Grade 2C).

Dietary treatment of eosinophilic esophagitis (EoE) traditionally has involved removal of multiple foods/food groups simultaneously. However, this approach is associated with poor adherence and can cause nutritional deficiencies. In a multicenter randomized trial of 129 adults with EoE that compared elimination of mammalian milk (1 food elimination diet [FED]) with removal of six foods/food groups (6FED), rates of histologic remission were similar between the two groups at six weeks (34 versus 40 percent, respectively) [9]. Improvements in disease-relatedquality-of-life scores and peak eosinophil counts were also similar. These results confirm earlier findings in a pediatric trial. For most patients with EoE who opt for a dietary approach to treatment, we suggest an initial empiric elimination diet of cow's milk (all forms of dairy/milk) plus cross-reacting mammalian milk (eg, goat's milk). (See "Dietary management of eosinophilic esophagitis", section on 'Efficacy of different dietary approaches'.)

NEUROLOGY (February 2023)

Mechanical thrombectomy for large ischemic core infarcts

●For patients with acute ischemic stroke, we recommend treatment with intra-arterial mechanical thrombectomy (MT), whether or not the patient received treatment with intravenous thrombolytic therapy, if the following conditions are met (Grade 1B): Brain imaging using CT without contrast or diffusion-weighted MRI (DWI) excludes hemorrhage and is consistent with an Alberta Stroke Program Early CT Score (ASPECTS) ≥3; CT angiography (CTA) or MR angiography (MRA) demonstrates a proximal large artery occlusion in the anterior circulation as the cause of the ischemic stroke; the patient has a persistent, potentially disabling neurologic deficit (eg, a National Institutes of Health Stroke Scale [NIHSS] score ≥6); the patient can start treatment (femoral puncture) within 24 hours of the time last known to be well. This recommendation applies when thrombectomy is performed at a stroke center with appropriate expertise in the use of endovascular therapy. Benefit may be most likely when imaging confirms the presence of salvageable brain tissue (eg, a mismatch by DAWN or DEFUSE 3 criteria).

Mechanical thrombectomy (MT) for acute ischemic stroke due to a large artery occlusion in the anterior circulation has been limited to patients with a small- to moderate-sized core infarct at baseline. The exclusion of patients with large core infarcts was first challenged in 2022 by results from the RESCUE-Japan LIMIT trial. The recent SELECT2 and ANGEL-ASPECT trials now confirm that MT compared with medical treatment alone improves outcomes for patients with a large ischemic core infarct (defined by an Alberta Stroke Program Early CT Score [ASPECTS] of 3 to 5 or a core volume ≥50 ml) [10,11]. As an example, the SELECT2 trial showed that functional independence for patients with large infarcts was more likely with MT than with medical care alone (20 versus 7 percent) [10]. Based on these results, in addition to previously defined eligible groups, we also recommend MT for patients who have a large ischemic core infarct as defined in these trials and can start treatment within 24 hours of the time last known to be well. (See "Mechanical thrombectomy for acute ischemic stroke", section on 'Benefit for large core infarcts'.)

PULMONARY AND CRITICAL CARE MEDICINE (January 2023)

New GOLD strategy for initial COPD pharmacologic management

●For patients with COPD who are less symptomatic and at low risk of exacerbation (group A), we suggest a long-acting bronchodilator rather than short-acting bronchodilators alone (Grade 2B). For patients with COPD who are more symptomatic or have a high risk of exacerbation (Groups B and E), we suggest initial treatment with dual long-acting bronchodilator therapy rather than a single long-acting bronchodilator alone (Grade 2C).

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 report identifies key changes for patients with COPD [12], specifically more aggressive initial bronchodilator therapy:

•Single-agent long-acting bronchodilator therapy for less severe symptoms and low exacerbation risk (Group A).

•Dual long-acting bronchodilator therapy for more severe symptoms and low exacerbation risk (Group B).

•Dual long-acting bronchodilator therapy for high exacerbation risk, regardless of symptoms (Group E, replacing previous Groups C and D categories).

It also redefines a COPD exacerbation as an event characterized by dyspnea and/or cough and sputum that worsens over ≤14 days with possible tachypnea and/or tachycardia caused by airway infection, pollution, or other insult to the airways. This new definition decouples exacerbations from their treatment, which had confounded earlier approaches. A new classification for severity of exacerbations was also outlined. (See "COPD exacerbations: Clinical manifestations and evaluation" and "Stable COPD: Initial pharmacologic management", section on 'Assessing disease pattern and severity'.)

PEDIATRICS (November 2022, Modified January 2023)

Semaglutide for obesity in adolescents

●For adolescents with refractory obesity who opt for pharmacologic therapy, we suggest subcutaneous semaglutide rather than other agents (Grade 2C).

Glucagon-like peptide (GLP-1) analogs are important options for treatment of type 2 diabetes and/or obesity in adults. In a 68-week randomized trial in 201 adolescents with obesity, patients assigned to weekly subcutaneous semaglutide, a GLP-1 analog, had substantial weight loss compared with lifestyle intervention alone (17.7 kg greater weight loss compared with placebo; 6 kg/m² greater decrease in body mass index [BMI]) [13]. Gastrointestinal adverse events were common in both groups but were generally mild and rarely led to treatment discontinuation. While head-to-head trials have not been performed in adolescents, indirect evidence suggests greater weight loss with semaglutide than the alternatives, including liraglutide and metformin. Based on these findings, we now suggest semaglutide over other agents for pharmacotherapy of obesity in selected adolescents. (See "Prevention and management of childhood obesity in the primary care setting", section on 'Pharmacotherapy'.)

EMERGENCY MEDICINE (ADULT AND PEDIATRIC) (December 2022)

Video laryngoscopy for emergency intubation in adults

●In an adult for whom laryngoscopy is indicated for emergency intubation, we suggest using a video laryngoscope instead of a direct laryngoscope (Grade 2B).

Video laryngoscopes (VLs) are rigid devices that allow glottic visualization without a direct line of sight, and they are increasingly being used for rapid sequence intubation in the emergency department. In a meta-analysis of 222 trials in adults (most in the elective surgery setting), Macintosh-style, hyperangulated, and channelled VLs all reduced the rate of failed intubation, increased first-pass attempt success, improved the glottic view, and reduced peri-intubation hypoxia compared with a direct laryngoscope (DL) [14]. Given these findings, we suggest using a VL, if available, instead of a DL when laryngoscopy is indicated for emergency intubation. (See "Overview of advanced airway management in adults for emergency medicine and critical care", section on 'Choice of laryngoscopy technique'.)

INFECTIOUS DISEASES (December 2022)

First trimester treatment of malaria with artemisinin derivatives

●For treatment of uncomplicated chloroquine-resistant Plasmodium falciparum malaria during the first trimester, we suggest treatment with artemether-lumefantrine, rather than a quinine-based regimen (Grade 2B). We also suggest artemether-lumefantrine for chloroquine-resistant non-falciparum malaria during the first trimester (Grade 2C).

Artemisinin combination therapy (ACT) has become the preferred treatment for uncomplicated malaria in most patients, but use for treatment of chloroquine-resistant malaria in the first trimester has been avoided because of limited safety data. However, in a 2022 meta-analysis of prospective data from >700 pregnancies with confirmed first trimester exposure to ACT and >1000 pregnancies with confirmed first trimester exposure to non-ACTs, adverse pregnancy outcomes occurred less often among those who received ACT, although the result was not statistically significant (5.7 versus 8.9 percent; adjusted hazard ratio [aHR] 0.71, 95% CI 0.49-1.03) [15]. Artemether-lumefantrine accounted for 70 percent of the ACT exposures and was associated with a lower risk of adverse pregnancy outcome compared with oral quinine (4.8 versus 9.2 percent; aHR 0.58, 95% CI 0.36-0.92). Based on these data, we now suggest artemether-lumefantrine for treatment of chloroquine-resistant malaria during the first trimester. (See "Malaria in pregnancy: Prevention and treatment", section on 'Drug safety'.)

NEPHROLOGY AND HYPERTENSION (November 2022)

Finerenone in patients with diabetic kidney disease

●Among patients with type 2 diabetes who have measured or estimated albuminuria ≥30 mg/day despite an angiotensin inhibitor and a sodium-glucose co-transporter 2 (SGLT2) inhibitor, we suggest treatment with a nonsteroidal selective mineralocorticoid receptor antagonist (MRA, specifically finerenone) (Grade 2B), where available.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors and finerenone (a nonsteroidal mineralocorticoid receptor antagonist) prevent important adverse kidney and cardiovascular outcomes in patients with diabetic kidney disease (DKD). The 2022 guidelines from the American Diabetes Association (ADA) and the Kidney Disease: Improving Global Outcomes (KDIGO) on the treatment of patients with DKD advise the use of SGLT2 inhibitors in all patients with DKD; they also advise the use of finerenone in patients who have increased albuminuria despite treatment with an angiotensin inhibitor and an SGLT2 inhibitor [16,17]. We agree with these guidelines and now suggest use of finerenone in patients with albuminuria despite other recommended therapies, except when serum potassium is elevated (serum potassium >4.8 mEq/L or estimated glomerular filtration rate <25 mL/min/1.73 m²). (See "Treatment of diabetic kidney disease", section on 'Type 2 diabetes: Treat with additional kidney-protective therapy'.)

NEPHROLOGY AND HYPERTENSION (November 2022)

SGLT2 inhibitors in patients with nondiabetic proteinuric chronic kidney disease

●In patients with chronic nondiabetic kidney disease with proteinuria (albuminuria ≥300 mg/day or proteinuria ≥500 mg/day), we recommend treatment with a sodium-glucose co-transporter 2 (SGLT2) inhibitor (Grade 1B).

Sodium-glucose co-transporter 2 (SGLT2) inhibitors are recommended in patients with diabetic kidney disease; previously, only one large trial examined their effects in nondiabetic chronic kidney disease. In the EMPA-KIDNEY trial, 6609 patients with estimated glomerular filtration rate (eGFR) 20 to 44 mL/min/1.73 m² (regardless of albuminuria) or 45 to 89 mL/min/1.73 m² (if albumin-to-creatinine ratio was at least 200 mg/g) were randomly assigned to empagliflozin 10 mg daily or placebo [18]. At two years, empagliflozin reduced the incidence of end-stage kidney disease, the incidence of a sustained decline in eGFR to <10 mL/min/1.73 m², and the incidence of a sustained decrease in eGFR of 40 percent or more; the risks of all-cause mortality and nonfatal cardiovascular events were similar between groups. The benefit from empagliflozin was larger in patients with albumin-to-creatinine ratio ≥300 mg/g and substantially less in patients with lower albumin excretion. We now recommend SGLT2 inhibitor therapy in patients with nondiabetic chronic kidney disease and albuminuria. (See "Overview of the management of chronic kidney disease in adults", section on 'Patients with proteinuria'.)

NEUROLOGY (October 2022)

Sodium phenylbutyrate-taurursodiol for amyotrophic lateral sclerosis

●For all patients with amyotrophic lateral sclerosis, we suggest treatment with sodium phenylbutyrate-taurursodiol (Grade 2B), in addition to riluzole and edaravone.

Sodium phenylbutyrate-taurursodiol (PB-TURSO) is a combination of two orally available drugs that each reduce neuronal cell death in preclinical models of amyotrophic lateral sclerosis (ALS). In a randomized trial of 137 patients with ALS (75 percent also taking riluzole and/or edaravone) who were within 18 months of symptom onset, patients assigned to PB-TURSO showed a slower median rate of monthly functional decline than those assigned to placebo by 24-week follow-up [19]. There were nonsignificant trends toward slower decline in both vital capacity and muscle strength with treatment. In a subsequent analysis of patients who continued open-label treatment (up to 35 months), those originally randomized to PB-TURSO had a longer median time to tracheostomy (26 versus 19 months) and a longer median time to first hospitalization [20]. Based on these results, the combination product received regulatory approval in the United States and Canada [21,22]. We now suggest use of PB-TURSO for all patients with ALS, along with riluzole (prioritized as initial therapy) and edaravone. (See "Disease-modifying treatment of amyotrophic lateral sclerosis", section on 'Efficacy'.)

GENERAL SURGERY (September 2022)

Role of wound packing after drainage of perianal and perirectal abscess

●For most patients with a perianal or perirectal abscess, we suggest not packing the wound after drainage (Grade 2C).

After incision and drainage of a perianal or perirectal abscess, it is common practice to pack the wound, under the assumption that this will facilitate further drainage by wicking and prevent premature skin closure. In the PPAC2 trial of 443 patients with a primary perianal abscess, nonpacking, compared with packing, resulted in similar rates of fistula formation (11 versus 15 percent) and abscess recurrence (6 versus 3 percent), differences that were not statistically significant [23]. However, the nonpacking group had lower average pain scores (28 versus 38 on a 100-point visual analog scale). Given these and similar findings from two earlier small trials, we now suggest not packing the wound after drainage of perianal or perirectal abscess. (See "Perianal and perirectal abscess", section on 'Role of wound packing'.)

CARDIOVASCULAR MEDICINE (September 2022)

Anticoagulation for rheumatic mitral stenosis with atrial fibrillation

●For patients with rheumatic mitral stenosis requiring anticoagulation (for atrial fibrillation, left atrial thrombus, or a prior embolic event), we recommend chronic anticoagulation with a vitamin K antagonist (eg, warfarin) rather than with a direct oral anticoagulant (Grade 1B). The target international normalized ratio is 2.5 (range 2.0 to 3.0).

Limited data have been available to guide anticoagulant choice in patients with rheumatic mitral stenosis and atrial fibrillation. A randomized trial enrolling over 4500 adults with rheumatic heart disease and atrial fibrillation found that the mortality and stroke rates were higher with rivaroxaban than with a vitamin K antagonist (VKA), and major bleeding rates were similar [24]. Based on these findings, for patients with rheumatic mitral stenosis and atrial fibrillation, we now recommend a VKA rather than a direct oral anticoagulant such as rivaroxaban. (See "Rheumatic mitral stenosis: Overview of management", section on 'Choice of anticoagulant'.)

PULMONARY AND CRITICAL CARE MEDICINE (August 2022)

Intravenous magnesium in severe COPD exacerbation

●For patients having an acute COPD exacerbation who experience limited benefit from short-acting inhaled bronchodilators, we suggest intravenous magnesium (Grade 2C).

Intravenous magnesium has short-acting bronchodilator activity that is helpful for severe asthma attacks, but it has not previously been recommended for chronic obstructive pulmonary disease (COPD). A new systematic review and meta-analysis found a decrease in hospitalization rates with emergency department intravenous magnesium administration compared with placebo [25]. The effect size is similar to or better than that seen in the setting of asthma exacerbation. Based on these data, we now suggest intravenous magnesium for patients with severe COPD exacerbations who are not improving with inhaled bronchodilator therapy. (See "COPD exacerbations: Management", section on 'Magnesium sulfate'.)