440 - Fasting Labs?, Actinic Keratosis Treatment, Powered by Apology
Take 3 – Practical Practice Pointers©
From the Guidelines
1) Are Fasting Labs Necessary Anymore?
A warning, this pointer is a bit unusual, evidence-wise…It started as a question about our hypertension measurements in the office. A colleague wondered why a number of their patients decided to not take their medication (usually antihypertensives and lipid medications) on the morning of their visit. Apparently, patients were “fasting” because they knew they were due for labs and thought that “fasting” applied to their medications. I cannot find anything in the literature about this phenomenon (although it would make a great primary care study). However, it brought to mind the issue of fasting lab tests and whether we should be asking our patients to fast anymore. This was covered last in Take 3 #59 in 2014! We thought we’d update it…
The two most common reasons to ask our patients to fast before blood work are: 1) testing for diabetes and 2) testing for hyperlipidemia.
Following and managing diabetes is largely accomplished by hemoglobin A1c nowadays, so we’re left with the initial diagnosis of diabetes. For diagnosis, there are 4 options:
· FPG ≥ 126. (Fasting defined as no caloric intake for at least 8 hours), OR
· 2-h PG ≥ 200 mg/dL during oral glucose tolerance test. (OGTT, with 75 g glucose), OR
· Hgb A1c ≥ 6.5%, OR
· In a patient with symptoms of hyperglycemia, a random plasma glucose ≥200
Most of us are not doing a lot of OGTTs for non-pregnant adults in our offices any longer, and hopefully we’re catching patients with hyperglycemia and random glucoses over 200 only occasionally. Which leaves A1c and fasting glucose for screening. A1c is still pretty variable in its results, despite the recent standardization that allowed it to be used for screening, and can still miss cases of diabetes. In addition, it can be incorrect in certain medical conditions: hemoglobinopathies, anemia, HIV treated with certain medications, and post-partum. Furthermore, several insurances (Medicare for example) do not cover A1c for screening for diabetes but do cover serum glucose measurements (including glucose challenge testing).
What about fasting lipid testing? With the 2013 ACC/AHA cholesterol guidelines, and continued in the 2018 updates, fasting lipid screening is no longer recommended routinely. With a greater ability to directly measure low-density lipoprotein (LDL) values despite the triglyceride levels, as well as the greater focus on the total cholesterol and high-density lipoprotein levels for initial diagnosis, routine fasting lipid panels are deemed unnecessary. There is only mention of fasting lipid panels in these guidelines for workups of hypertriglyceridemia.
I try to resist the phrase, “more research is needed” here, but in this case, it applies. It’s safe to say that for routine screening and testing purposes, there is no requirement for fasting, and if it causes our patients to come to our office having not taken their blood pressure medications, then we should do what we can to discourage this. However, there are specific instances in diabetes testing and lipid management where fasting may be appropriate as an exception to the general rule.
· American Diabetes Association Professional Practice Committee. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2022. Diabetes Care. 2021;45(Supplement_1):S17-S38. Link
· Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596-e646. Link
From the Literature and the American Academy of Dermatology (AAD)
2) Management of Actinic Keratoses
Actinic keratosis (AK) is one of the most common conditions diagnosed and treated by dermatologists in the US, and is commonly treated by primary care clinicians as well. In 2021, the America Academy of Dermatology published a practice guideline for the management of AK. Various AK treatments, including topical agents, cryosurgery, and photodynamic therapy (PDT) were reviewed. In the guideline, clinical characteristics, histologic classification, natural history, risk of progression, and dermatologic surveillance of AKs were discussed. The AAD notes that because treatment of AK is likely to be an ongoing process for most patients, and one that is usually accompanied by some level of discomfort, the choice of optimal therapy will ideally involve shared decision-making between the clinician and the patient.
Recommendations include (strength of recommendation/quality of evidence):
· For patients with AK, recommend the use of UV protection, including include sun avoidance, sun-protective clothing, and broad-spectrum sunscreen (Strong/Good).
· Treat with 5-fluorouracil or imiquimod (Strong/Moderate)
· Consider treatment with diclofenac (Conditional/Low)
· Treat with cryosurgery (Strong/Good)
· Consider use of cryosurgery over CO2 laser ablation (Conditional/Moderate)
· Conditionally recommend photodynamic therapy (PDT), including aminolevulinic acid (ALA)–red light PDT, ALA-daylight PDT, or ALA-blue light PDT (Conditional/Low)
· Conditionally recommendation 5-fluorouracil/cryosurgery over 5-FU alone (Conditional/Moderate)
· Conditionally recommend imiquimod/cryosurgery over imiquimod alone (Conditional/Low)
This is certainly a common problem in primary care, and one we should be routinely both diagnosing and treating. Topical 5-FU is not something I became comfortable prescribing until well past my residency training. For lesions on areas other than the face/scalp, use 5% cream applied once or twice daily for two to four weeks until superficial erosion occurs. some clinicians have found adding a topical steroid can decrease improve tolerance and therefore adherence. To improve tolerability and therefore adherence to treatment, some clinicians use the 5-FU in combination with topical corticosteroids. For lesions of the face/scalp, use the 0.5% fluorouracil applied once daily for up to four weeks.
If choosing imiquimod, the 5% cream is typically used for non-face/scalp lesions and is applied to the involved area for 8 hours twice weekly for 16 weeks. For face/scalp lesions, lower concentration preparations containing 2.5% and 3.75% imiquimod should be applied once daily for two weeks, stop for 2 weeks, then repeat once daily for another two week cycle.
For cryotherapy, an open-spray technique is recommended for 15 seconds with 1 mm margins. This does not usually need to be repeated but can be after 10 days if necessary. For an updated primer on cryotherapy in general, see the 2nd and 3rd references below.
· Eisen DB et al. Guidelines of care for the management of actinic keratosis. J Am Acad Dermatol; 2021 Apr 2. Link
· Cranwell W and Sinclair R. Optimizing Cryosurgery Technique. Austral Fam Phy May 2107 (46)5: 270-274. Link
· Clebak, K et al. Cutaneous Cryosurgery for Common Skin Conditions. Am Fam Physician. 1 Apr 2020;101(7):399-406. Link
From PeerRxMed (www.PeerRxMed.org)
3) Can We Start Over? Re-Connection Powered by Apology
“Apologizing … means you value your relationship more than your ego.” Mark Matthews, author
It was one of those mornings when, for whatever reason, the universe seemed to be conspiring against me and I was primed for frustration. I had forgotten about a deadline and had a challenging clinical day ahead of me. When I arrived at work, logging onto the network seemed to take forever and changes from a recent “upgrade” on our EMR had me a bit out of sorts (so to speak). As I started clinic, my N95 mask was making communication with some of my hard-of-hearing patients particularly challenging, and then, of course, everyone I had seen so far that morning, in addition to their lengthy “list,” had saved the significant “by the way” until my hand was on the door to leave the room. Likely you can relate.
Now running behind, I had taken on a bit of an “attitude” as I prepared to enter the room of a patient I had never seen before who in reviewing his chart had terminal cancer and was experiencing intractable vomiting. “Why didn’t the front desk direct him to the ED?!” I asked my nurse. “The family insisted on bringing him here,” was her reply. I sighed and may have rolled my eyes …
So I entered the room carrying an emotional charge that was, let’s just say, “not positive.” There in the small exam room were 4 people, including the patient, who was already lying on the exam table and obviously not well. The tension in the air was palpable. After brief introductions, I asked, “How can I help you today?”, my mask hiding my scowl, but perhaps not my scowling eyes and tone. “Dad can’t stop vomiting,” was the reply from one of the daughters. “I see you spoke with your oncologist yesterday and they recommended going to the ED. Why didn’t you do that?” My impatience and frustration were already showing.
And then two very unexpected things happened. The patient started to cry and said, “I thought you’d be able to help me. I’m just so scared …” and I also became tearful, could feel my demeanor softening, and these words came out of my mouth from somewhere deep inside me: “I’m sorry. I came into this room carrying much of my morning, which has been challenging for me. That’s not fair to you. Can we start over?”
We did. And in that transition, my presence, rather than being toxic, became salve for 4 hurting and scared souls. Somehow miraculously my “pity party for Mark” turned into a celebration of a life that, unbeknownst to us at the time, was to end 5 days later. Tension was replaced by Holy tears as the family shared important and incredibly loving sentiments that had been withheld due to a fear of giving the impression that they had “lost hope.” And it all happened because a lost connection was found again, powered by an apology …
Where are those reconnections waiting to happen in your life …?
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.