471 - Conjunctivitis in Kids, Anti-obesity Medications, Change Influencers
Take 3 – Practical Practice Pointers©
From the Literature
1) Conjunctivitis in Kids
Infectious conjunctivitis in children is a common malady. Most (>80%) is caused by bacteria (in adults, most is viral). Despite the bacterial cause, conjunctivitis is often self-limiting. An unusual report of both a randomized clinical trial (RCT) AND a systematic review was published in JAMA Network Open recently.
In the trial, 88 children (age 6 months to 7 years) were randomized to empiric antibiotics (moxifloxacin drops for 7 days), placebo eyedrops or no treatment. This third arm was considered important because the authors postulated that some of the lack of effectiveness seen in antibiotic eyedrop studies in the past was due to a combination of the “washout” effect (literally washing the eye out with the placebo solution) or to the presence of antiseptics in the drop solution as preservatives. The authors measured time to resolution of symptoms. The moxifloxacin group improved 1.9 days earlier (3.8 days vs. 5.7 days, 95% CI -3.7 to 0.1 days). Both moxifloxacin and placebo shortened the duration of symptoms, but five children who got antibiotics had relapsing symptoms whereas only 2 in the placebo group and 1 in the no intervention group had relapse.
The systematic review (3 RCTs - including the above trial - and 1 subgroup analysis of an RCT, n = 584) was done to evaluate the role of antibiotic eyedrops in clinical infectious conjunctivitis in children. Studies that evaluated RCTs of antibiotic eyedrops vs. placebo were included from a comprehensive search. The meta-analysis had non-significant amounts of heterogeneity and there was no significant publication bias. A greater proportion of patients on antibiotic drops (polymyxin-bacitracin, chloramphenicol or 2 different quinolones) were symptom-free at 3-6 and 7-10 days than on placebo.
Antibiotic drops do appear to shorten the duration of symptoms of infectious conjunctivitis in children (who are more likely to have a bacterial cause). The question of whether improvement on placebo drops is due to washout, antiseptic preservatives or just the placebo effect is not clear from this study. There was a difference in symptom relapse in the trial, but there was no data about this phenomenon in the review. The combination of the RCT and systematic review with consistent findings is a helpful push to change my practice.
Honkila M, Koskela U, Kontiokari T, et al. Effect of Topical Antibiotics on Duration of Acute Infective Conjunctivitis in Children: A Randomized Clinical Trial and a Systematic Review and Meta-analysis. JAMA Netw Open. 2022;5(10):e2234459. Link
From the American Gastroenterological Association (AGA) Guidelines
2) Use of Anti-obesity Medications for Weight Management
The prevalence of adult obesity in the US was estimated to be 42% according to 2019-2020 data National Center for Healthcare Statistics data. This has contributed to a rise in obesity-related complications, such as cardiovascular disease, stroke, type 2 diabetes mellitus (T2D), nonalcoholic steatohepatitis, obstructive sleep apnea, osteoarthritis, and certain types of cancer (eg, colorectal cancer). Lifestyle interventions are the foundation for management of obesity, but for multiple reasons, its effectiveness and sustainability has been limited for many.
Pharmacological therapies have been developed and approved for long-term management of obesity, with high efficacy in achieving weight loss. However, there is limited use of these agents in routine clinical care with wide practice variability, and a small number of clinicians are responsible for a significant majority of the prescriptions. This seems to be due to lack of familiarity and comfort with the medications, questions about long-term efficacy, cost, limited access, and insurance coverage.
Given this gap, the American Gastroenterological Association (AGA) recently published evidence-based recommendations for the pharmacological management of obesity in adults. Evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Each recommendation includes a determination for the Strength of Recommendation (SOR = Strong or Conditional) and Quality of Evidence (QOE = High, Moderate, Low, Very Low).
The evidence-to-decision framework was used to formulate recommendations through consensus of the 10-member multidisciplinary expert panel, including a patient representative. This framework assesses and weighs the magnitude of and balance between the benefit and harms of interventions, patients’ values and preferences, and the domains of feasibility, acceptability, and resource requirements and the impact on health equity. Cost and cost-effectiveness did not drive a decision.
The outcomes utilized for decision making included percent total body weight loss (%TBWL), proportion of patients achieving ≥5%, ≥10%, and ≥15% TBWL, treatment discontinuation due to adverse event, and serious adverse events (SAEs). The evidence synthesis panel determined a priori that the minimal clinically important difference (MCID) for the efficacy of pharmacotherapy that corresponded to important patient benefits was a mean difference (MD) of 3% TBWL between pharmacotherapy plus lifestyle over lifestyle alone or an absolute 5% TBWL over baseline.
All recommendations were for either adults with obesity or those with overweight having weight-related complications. Recommendation summary includes:
· For those who have had an inadequate response to lifestyle interventions, recommend adding pharmacological agents to lifestyle interventions over continuing lifestyle interventions alone. (Strong/Moderate)
· Suggest the use of semaglutide (Ozembic, Wegovy, Rybelsus) 2.4 mg , liraglutide (Victoza and Saxenda) 3.0 mg, phentermine-topiramate ER (Qsymia), or naltrexone-bupropion ER (Contrave), in addition to lifestyle interventions, compared with lifestyle modifications alone. (Conditional/Moderate)
· Suggest against the use of orlistat. (Conditional/Moderate)
· Suggest using phentermine (Lomaira and Adipex-P) or diethylpropion (Tenuate), in addition to lifestyle modifications, compared with lifestyle modifications alone. (Conditional/Low)
· In adults with BMI between 25 and 40 kg/m2, recommend using Gelesis100 oral superabsorbent hydrogel (Plenity) only in the context of a clinical trial. (No Recommendation/Knowledge Gap)
When it comes to anti-obesity medications, I must confess that I struggle. Not because I don’t think they have an important place in our therapeutic armamentarium, but rather that I see them used too often instead of, rather than in addition to, lifestyle interventions. And because of the cost concerns for some of the medications, I’ve seen too many patients lose weight while on them, only to regain it again when they are discontinued. Having said that, the disease of obesity is epidemic, and we owe it to our patients to do what we can to help.
Note as well that tirzepatide (Mounjaro) is a new “twincretin”, with dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist activity. This medication is approved for use in in T2D, and now has fast track designation for weight loss from the US Food and Drug Administration. I’m seeing it being used by many because of some initial incentives from the manufacturer. As noted above, I worry about the longer-term effectiveness if/when the price is increased or incentives are discontinued, particularly among vulnerable populations.
A comment about Plenity as well. Though taken orally, it is considered a “medical device” by the FDA due to its mechanism of action. While it has become popular among patients due to aggressive marketing, there is only a single RCT informing low certainty evidence for its effectiveness. As such, the AGA made no recommendation on its use.
Grunvald E, et al on behalf of the AGA Clinical Guidelines Committee. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults with Obesity. Gastroenterology November 1, 2022. 165(50):1198-1225. Link
From PeerRxMed ( www.PeerRxMed.org )
3) Looking For Some Good Influencers to Tame the “Cookie Monster”
“You are a product of your environment. Choose the environment that will best develop you toward your objective …. Is it helping you toward success—or holding you back?” — W. Clement Stone
In last week's blog, we continued the journey of trying to understand why, when it comes to behavior change, it is often so difficult to travel “the longest yard” – the distance between our knowledge (head), our beliefs (heart) and our action (hands). We concluded that, try as we might, we’ll never outSMART our emotions, so we need learn how to better direct their powerful energy in the direction we desire to go.
Using the analogy of the rider (knowledge/“skill”), the elephant (emotions/“will”), and the path (environment), it is now time to explore what I have come to believe is a greatly underutilized aspect of behavior change – the path. How do we create the circumstances that will optimize the chances that change will both occur and be sustainable? Well, it turns out that behavior change at its best requires both the support of others and the right conditions and tools.
In their book Influencer: The New Science of Leading Change, Joseph Grenny and colleagues proposed that for change to really take hold, it must maximally tap into 6 sources of influence, and that personal “will and skill” are only two of them. This provides some hope for me, since we established last week that while I have the skill to resist those cookies, I appear to be lacking the will, so I’m going to need some help! The other 4 influencers comprise the “path” of behavior change – the social and structural environment within which the change is to take place, and both of these has their own “will and skill” component as well. The authors argue that unless at least 4 of these 6 sources of influence are leveraged, any attempt at change doesn’t stand a chance. One down, and at least three to go for the Cookie Monster! Let’s get started.
The “social” aspect of the path has to do with how others are helping or hindering the desired change. This is where your PeerRxMed partner can start taking on a major role in impacting your road to change! Consider how powerful receiving encouragement has been on your professional journey. This is because encouragement is the ultimate “elephant fuel.” Indeed, to encourage literally means “to cause to be in heart,” and as we learned last week, it's the "heart" (emotion) that drives the "will" of any behavior change. So inviting others to encourage my desire to forego my cookie-eating tendencies (can’t have just one) becomes a significant influencer for that change. But encouragement is not enough. Think back to your own medical training and reflect on some of your best teachers. They not only encouraged you, but also helped to equip you through their teaching and example. I need to find a friend who has cracked the “cookie code” to share their wisdom and help me do the same.
The final 2 major influencers for change have to do with the structural part of your change path. This has to do with creating the right conditions and using the right tools. In my quest to tame the Cookie Monster, not having cookies in the house (will) and having healthier snacks readily available that I also like (skill) would be an important way to modify that “pathway of least resistance” that we humans are hardwired for.
What’s the path you are creating on your way to change and how can you modify your “influencers.” When I do the math for my cookie “conquering,” it appears I’m well on my way. For too many of us, however, we keep our change efforts to ourselves to avoid a sense of vulnerability, and in doing so, fail to tap into the powerful structural and social “capital” that surrounds us. Don’t let that be you! Your PeerRxMed partner is an invitation away from helping to provide vital support on your change journey. Allow them to help you check off 2 more “influencer” sources, then perhaps together you can plan how to create the optimal structure for change success. With all these resources at your disposal, it seems like sanity that no one should try to change alone.
Next week, in our final segment of this series, we’ll return back to you as the ultimate catalyst of change and explore how applying a few key principles can create the circumstances for your new “that’s just what I do.”
Mark and John
Carilion Clinic Department of Family and Community Medicine
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