Question

Discussion Board – Review Chapter 14 Clinical Encounter vignettes and share your thoughts on your chosen vignette and add support to your views using sources referenced in APA Clinical

Clinical-Encounter Vignette Part II: Treatment Options for a Patient Diagnosed with GERD Dr. Lore prescribes an anti-GERD medication that has been used with some success for many years, as is his habit in these cases. His experi- ence with a newer, more expensive medication is still limited, so he tends to avoid prescribing it. In contrast, Dr. Skeptic again thinks about the evidence base regarding medications for GERD. He considers the older medicine but reviews the evidence comparing the older medicine to the newer one (Moayyedi and Talley 2006; Revicki et al. 1999; Thomson et al. 1998). Because of the newer drug’s pharmacology, biological plausibility supports the idea that it may better control GERD. In fact, there is evidence, from several head-to-head randomized comparisons of the older versus the new medicine, that shows the newer medicine con- trols symptoms better. However, the newer medication costs about four times as much. The comparison literature includes cost-effective- ness studies favoring the newer medication. Finally, Dr. Skeptic notes that the newer medication now has more than 12 years of reported studies about its efficacy and safety, and he is satisfied that it has a low risk of serious side effects. From the evidence available to him, Dr. Skeptic concludes that the newer medication should be prescribed. Both doctors have also diagnosed hypertension in Mr. Brown. From basic medical knowledge and experience, they both know that hypertension increases the risk of heart attack and stroke and that the standard of care is to treat hypertension with medication along with advice to cut down on salt, exercise more, and lose weight. Currently, more than 75 different drugs for the treatment of hyper- tension are available on the US market. Dr. Lore likes to prescribe a newer antihypertensive medication (we’ll call it Newpress) because it is heavily advertised to keep blood pressure down with a low incidence of side effects, and his favorite cardiologist has touted Newpress as a great drug. Like many newer drugs for high blood pressure, it costs five to ten times as much as older, off-patent antihypertensives. Dr. Lore tells Mr. Brown that he is at high risk for heart attack, stroke, and kidney failure because of his high blood pressure. He prescribes Newpress and explains that such medication will probably be required for the rest of Mr. Brown’s life. Mr. Brown reluctantly accepts this fate, which Dr. Lore tells him he must if he wants to avoid a heart attack, stroke, or kidney failure. Dr. Skeptic is gratified that for hypertension treatment, an exten- sive body of evidence exists that can guide his treatment recommen- dations for Mr. Brown. He considers the following: 1. Onthebasisofmultipleobservationalstudiesandclinicaltrials involving thousands of patients with high blood pressure, Dr. Skeptic can estimate Mr. Brown’s combined risk of heart attack or stroke to be 10 percent to 15 percent over the next ten years. Treating his hypertension can be expected to reduce this risk by about one-fifth (Pearce et al. 1998). His risk of kidney failure in the next ten years is less than 0.3 percent (Klag et al. 1996), and treatment has not been proven to push that risk even lower in patients with normal kidney function (Jaimes, Galceran, and Raij 1996). 2. Reducing salt intake, avoiding alcohol, exercising, and losing weight may lower Mr. Brown’s blood pressure to the high-normal range, but probably will not get it down to a level at which it poses no risk (Chobanian et al. 2003). 3. Five types of older, inexpensive antihypertensive drugs have been proven to prevent heart attacks and strokes without serious side effects (Task Force for the Management of Arterial Hypertension 2013), but Newpress has not been tested in this manner. 4. When compared directly with each other in RCTs, six major classes of antihypertensive drugs share similar rates of side effects (Neaton et al. 1993). Newpress belongs to one of those classes, but Newpress has never been directly compared in controlled clinical trials with other antihypertensives. On the basis of this information, Dr. Skeptic advises Mr. Brown that it is acceptably safe to spend a few months trying to get his blood pressure under control through changes in lifestyle but that he may still need antihypertensive medication. The current evidence strongly favors drugs known as thiazides, ACE-inhibitors, calcium channel blockers, angiotensin receptor blockers, and beta-blockers because they have been proven to improve health (not just lower blood pres- sure). Therefore, Dr. Skeptic will prescribe one of these proven drugs if Mr. Brown’s blood pressure is still elevated after a few months of trying lifestyle modifications. He will see Mr. Brown every few weeks, adjusting the treatment regimen until his blood pressure is controlled without unacceptable side effects.

Answer 1