472 - Steroids for Back Pain, Metabolic/Bariatric Surgery, Going Atomic

From the Cochrane Library

1)  Oral Steroids for Back Pain

Oral steroids seem to have caught on fast as a treatment for back pain. They are, of course, potent anti-inflammatory medications. Since muscular and radicular back pain can both involve inflammation, it may make some sense to consider these medications, but recent back pain treatment guidelines have not recommended their use. Oral steroids can have dramatic long-term side effects, from gastritis and GI bleeding, psychiatric effects, and osteoporosis. In the short term, they can cause hyperglycemia. This Cochrane review addresses the benefits and harms of oral corticosteroids in treating radicular and non-radicular back pain as well as spinal stenosis pain.

The review included adults with acute or chronic low back pain, whether it be radicular, non-radicular, or due to spinal stenosis. Studies could be from the emergency room, specialty office, or primary care and included several different glucocorticoid options (prednisone, prednisolone, dexamethasone, etc.). Pregnant women were included if trials included them incidentally, but trials were excluded if they focused on pregnancy. The review looked for evidence of improvement in pain, function, and quality of life, as well as global improvement and harms.

The authors performed a comprehensive search, used the usual risk of bias assessment methods, and looked for heterogeneity – all per standard Cochrane protocol. They ultimately found 13 studies, nine of which studied radiculopathy (plus 2 studies each on non-radicular and spinal stenosis pain). Risk of bias of the included studies a range of quality of studies from low to high risk.

For radicular back pain, the review found small improvements in pain and function from corticosteroids at short-term follow up, but the clinical significance of these was questionable. There was uncertain evidence about harms overall, and low certainty about risk of hyperglycemia from these short-course steroids. For non-radicular back pain, overall evidence levels were low, but there was a concern for slightly more pain with steroids, minimally improved function, and fewer adverse events with steroid treatment. For spinal stenosis, steroids did not affect pain or function, and there was insufficient evidence to assess harms.

John’s Comments: 

It’s frustrating to have so little evidence for something that we see increasingly commonly prescribed. Given the results of this review – I will restrict my prescribing of corticosteroids to patients with lumbar radicular pain and will feel a little better that I would not see major side effects. Steroids do not yet appear to have a role in non-radicular back pain or spinal stenosis.

References:

·         Chou R, Pinto RZ, Fu R, et al. Systemic corticosteroids for radicular and non‐radicular low back pain. Cochrane Database of Systematic Reviews. 2022;(10). Link

From a Joint Statement by ASMBS and IFSO

2)  New Recommendations for Metabolic and Bariatric Surgery (MBS)

In 1991 the National Institutes of Health (NIH) convened a Consensus Development Conference that published a Statement on the indications for gastrointestinal surgery for severe obesity and recommendations for practice.  This Statement has been used as a standard for selection criteria for bariatric surgery, and includes a body mass index (BMI) ≥40, or BMI ≥35  with co-morbidities as the threshold for surgery.  Since that time, numerous studies have been published about the worldwide obesity epidemic and global experience with metabolic and bariatric surgery (MBS), which has greatly enhanced the understanding of obesity and its treatment, including data that have demonstrated that under the right conditions, MBS can produce superior weight loss and metabolic outcomes compared with nonoperative treatments.

The operations commonly performed have evolved as well, and older surgical approaches have been replaced with safer and more effective ones.  Currently, the dominant procedures are sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), together accounting for approximately 90% of all operations performed worldwide.  Additionally, MBS is now preferably performed using minimally invasive surgical approaches (laparoscopic or robotic assisted).

In light of significant advances in the understanding of the disease of obesity, its management in general, and metabolic and bariatric surgery specifically, the leadership of the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) convened to produce recently published joint statement on the current available scientific information on metabolic and bariatric surgery and its indications.

Recommendations include:

·         Long-term data consistently demonstrate the safety, efficacy, and durability of MBS in the treatment of clinically severe obesity and its co-morbidities, with a resultant decreased mortality compared with nonoperative treatment methods.

·         MBS is recommended for individuals with BMI ≥35, regardless of presence, absence, or severity of co-morbidities.

·         MBS is recommended in patients with T2D and BMI ≥30.

·         MBS should be considered for those with a BMI of 30–34.9 who do not achieve substantial or durable weight loss or co-morbidity improvement using nonsurgical methods.

·         Obesity definitions using BMI thresholds do not apply similarly to all populations. Clinical obesity in the Asian population is recognized in individuals with BMI >25. Access to MBS should not be denied solely based on traditional BMI risk zones.

·         Older individuals who could benefit from MBS should be considered for surgery after careful assessment of co-morbidities and frailty.

·         Children and adolescents with BMI >120% of the 95th percentile and a major co-morbidity, or a BMI >140% of the 95th percentile, should be considered for MBS after evaluation by a multidisciplinary team in a specialty center.

·         MBS is an effective treatment of clinically severe obesity in patients who need other specialty surgery, such as joint arthroplasty, abdominal wall hernia repair, or organ transplantation.

·         The ultimate decision for MBS readiness should be determined by the surgeon.

·         Severe obesity is a chronic disease requiring long-term management after primary MBS. This may include revisional surgery or other adjuvant therapy to achieve desired treatment effect.

Mark’s Comments:

These recommendations (which some are calling “guidelines”) make a bold statement regarding the effectiveness of metabolic and bariatric surgery for the treatment of obesity and expand eligibility substantially.  Given the potential far-reaching implications of such a change, it is important that we put on our “critical thinker” hats when assessing their conclusions.  I was very disappointed that the authors did not provide a detailed explanation of methodology and did not follow what has come to be the accepted standard processes for evidence grading and rating the strength of recommendation.  The credibility of their conclusions would have also carried more weight for me had they included bariatric experts from outside of surgery in their process as well as experts in literature review and data synthesis.  Additionally, that there was no mention of standards for on-going care after surgery gave the impression that this was not an important component of the effectiveness of MBS.

The article did not include any conflict-of-interest disclosures, which is vital for a document created by a group that has a very vested interest in the intervention being promoted.  This along with some very confidently worded statements in the recommendation left me with this sense that their position was, “Trust us, MBS works and it’s really good.”  It may be, and I certainly want to do all I can to help stem the tide of the epidemic of obesity we are experiencing, but we should expect more in terms of transparency and rigor in 2022 for such an important document.  As it stands, I retain some skepticism as to the real-world effectiveness of MBS across diverse populations and view it as an important option in a select group of well-screened, informed, and supported patients, rather than the cure-all these recommendations appear to espouse.

Reference:

Eisenberg D, et al.  2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO):  Indications for Metabolic and Bariatric Surgery.  Surg for Obes and Relat Dis.  Published ahead of print October 20, 2022. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Using Atomic Power to Break the Spell

“Every action you take is a vote for the person you wish to become.”  James Clear, Atomic Habits

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 were reminded that behavior change is a complex process that involves principles of neuroscience, behavioral science, social science, and design science, and that the wisest approach to taming the Cookie Monster (or any behavior change) was to not try and do it alone.       

To conclude our journey, we’re going to examine how using atomic power can help guide us successfully through the many “longest yards” of our life and “break the spell” of some of our automatic behavior while establishing new behavior patterns.   The “atomic power” in this case are the small, reproducible action steps that are foundational to creating all behavior change and when repeated over time become habits.

In his book Atomic Habits, author James Clear describes the 4 stages of a habit, which he calls cue, craving, response, and reward.   A behavior starts with a cue which triggers a craving, which motivates a response, which provides a reward, which satisfies the craving and, ultimately, becomes associated with the cue.   When all 4 stages work together, they form a neurological feedback loop that ultimately allows you to create automatic habits.

He goes on to describe how we can transform these four stages into a practical framework that can be used to create good habits and eliminate bad ones, which he calls the Four Laws of Behavior Change.   For creating a good habit, the process is to make the cue obvious, make the craving attractive, make the response easy, and make the reward satisfying.  To break a habit, the opposite is true; make it invisible, unattractive, difficult, and unsatisfying.  When all these “levers” are in the right position, a behavior becomes an effortless habit.  

So how might this process work to break the spell Cookie Monster seems to hold over me?  Well, my cue is hunger after I come home from work, so not having cookies in the house (invisible) is a good place to start.  Reminding myself that cookies in the evening regularly cause reflux might make them less attractive.  Having easy access to healthier snacks that I like (carrots and hummus) will help as well.  With no cookies in the house, I’d have to go buy them at the store (difficult).  Brushing my teeth immediately after dinner will alter their taste (unsatisfying).  If I’m bold, I could top it off with an agreement with my PeerRxMed partner to check in about  my progress regularly, where any “confessions” would be both unattractive AND unsatisfying.  Finally, having a vision for my physical health and appearance and creating a fun “Cookie Monster” mantra (“Cookie Monster is my friend, not food”) will provide additional rewards (satisfying) for choosing healthier behavior.  Applied together, the “atomic levers” are ready to deploy.  

What about you?  How might applying these 4 laws help you break a bad habit or help catalyze the formation of good one?  Why not pick one and go through the simple but powerful steps above to see where you might not be tapping into your atomic power, remembering to both grace yourself and laugh at yourself along the way.  Soon enough you’ll be able to declare “that’s just what the new me does.”  As for me, now that Cookie Monster and I are headed for a healthier relationship, it’s time to take on 3 more dietary adversaries, whom I fondly refer to as the “Tos Trio” – Doritos, Fritos, and Cheetos.  Game on!

______________

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.

Email: mhgreenawald@carilionclinic.org