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We sought to summarize current recommendations for the diagnosis of diarrhea-predominant irritable bowel syndrome (IBS-D) and describe available management options, highlighting a newer US Food and Drug Administration (FDA)-approved agent, eluxadoline.Literature on IBS-D was assessed up to January 2020 using PubMed, with key search terms including "IBS-D diagnosis", "IBS-D management", and "eluxadoline".IBS is a common gastrointestinal disorder affecting up to 14% of US adults and is particularly prevalent in women and those aged under 50. Symptoms include abdominal pain associated with altered bowel habits (i.e. diarrhea and/or constipation subtyped based on the predominant stool pattern). As IBS-D is challenging to manage with varying symptom severity, effective treatment requires a personalized management approach. Evidence-based therapeutic options endorsed by the American Gastroenterological Association and the American College of Gastroenterology can be used to effectively guide treatment. Dietary and lifestyle modifications, including adequate hydration, reducing caffeine and alcohol intake, and increasing soluble fiber intake may lead to symptom improvement. Over-the-counter medications such as loperamide are frequently recommended and may improve stool frequency and rectal urgency; however, for the outcome of abdominal pain, mixed results have been observed. Several off-label prescription medications are useful in IBS-D management, including tricyclic antidepressants, bile acid sequestrants, and antispasmodics. Three prescription medications have been approved by the FDA for IBS-D: alosetron, eluxadoline, and rifaximin.IBS-D can be effectively managed in the primary care setting in the absence of alarm features. Benefits and risks of pharmacologic interventions should be weighed during treatment selection.

Comprehensive care of diabetes requires satisfactory stewardship of an underutilized prescription in diabetes management: the prescription for structured blood glucose monitoring (BGM). Structured BGM is a recommended schedule of actionable blood glucose measurements taken at specific times with the intent of using the data for individualized patient education and therapeutic intervention. The utility of different BGM protocols is logically dictated by a patient’s therapeutic regimen. This article reviews the prescription for structured BGM in the setting of intensive insulin, nonintensive basal insulin, and noninsulin treatment regimens. Evidence-based prescriptions of structured 5- to 7-point BGM profiles in diabetes provide essential information for productive clinician- and patient-directed therapeutic interventions. The effective implementation of structured BGM aids clinicians in achieving the desired goal of A1C reduction while bolstering patient education and empowering self-management.

IN BRIEF Basal insulin therapy is well established for glycemic control in patients with diabetes but often is not optimally implemented, leading to poor clinical outcomes and adherence. Primary care providers can and should work together with other members of the diabetes care team to allow for effective titration of basal insulin that involves patients and their caregivers. Adequate guidance and monitoring during the titration process can minimize some of the adverse effects caused by basal insulin administration, while improving glycemic control in a timely manner.

Primary care teams provide the majority of poststroke care. When optimally configured, these teams provide patient-centered care to prevent recurrent stroke, maximize function, prevent late complications, and optimize quality of life. Patient-centered primary care after stroke begins with establishing the foundation for poststroke management while engaging caregivers and family members in support of the patient. Screening for complications (eg, depression, cognitive impairment, and fall risk) and unmet needs is both a short-term and long-term component of poststroke care. Patients with ongoing functional impairments may benefit from referral to appropriate services. Ongoing care consists of managing risk factors such as high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia. Recommendations to reduce risk of recurrent stroke also include lifestyle modifications such as healthy diet and exercise. At the system level, primary care practices can use quality improvement strategies and available resources to enhance the delivery of evidence-based care and optimize outcomes.

Jeffrey Gudin,1,2 Lynn R Webster,3 Emileigh Greuber,4 Kip Vought,4 Kalpana Patel,4 Louis Kuritzky5 1Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA; 2Department of Anesthesiology and Pain Management, Englewood Hospital and Medical Center, Englewood, NJ, USA; 3Scientific Affairs Neurosciences, PRA Health Sciences, Salt Lake City, UT, USA; 4Global Research and Development and Medical Affairs, Scilex Pharmaceuticals Inc, Palo Alto, CA, USA; 5Community Health and Family Medicine, University of Florida Community Health & Family Medicine, Gainesville, FL, USACorrespondence: Lynn R WebsterVice President Scientific Affairs, PRA Health Sciences, Salt Lake City, UT, 84103, USATel +1 801 904 4593Email WebsterLynn@Prahs.comPurpose: The primary objective was to evaluate adhesion performance of the lidocaine topical system 1.8% for 12 hours in healthy human subjects in three studies: as a single product (Study 1) and versus other lidocaine topical products (lidocaine patch 5% and lidocaine medicated plaster 5% [Study 2] and generic lidocaine patch 5% [Study 3]). Safety of the lidocaine topical system 1.8%, with a skin irritation focus, was a secondary objective.Patients and Methods: All three studies were open-label, randomized, Phase 1 adhesion performance studies in healthy adult volunteers (N=125). Lidocaine topical products were applied for 12 hours per test, per study arm. Adhesion of all test products was scored at 0, 3, 6, 9, and 12 hours post-application. Skin irritation was scored after product removal or when a product detached.Results: Overall, the majority (≥ 75%) of subjects treated with the lidocaine topical system 1.8% demonstrated ≥ 90% adhesion (FDA adhesion score 0) throughout the 12-hour administration period versus 13.6% of subjects treated with lidocaine patch 5%, 15.9% of subjects treated with lidocaine medicated plaster 5%, and 0% of subjects treated with the generic lidocaine patch 5%. There were no complete detachments with the lidocaine topical system 1.8%, whereas 4.5% of lidocaine patch 5% and lidocaine medicated plaster 5% detached, and 29% of generic lidocaine patch 5% detached. Minimal skin irritation was observed with each lidocaine topical product.Conclusion: Across three studies, lidocaine topical system 1.8% demonstrated superior adhesion performance versus the three other products tested. Skin irritation was minimal across products and studies.Clinicaltrials.gov: NCT04312750, NCT04320173, NCT04319926.Keywords: lidocaine topical system, lidocaine patch, lidocaine medicated plaster, adhesion, postherpetic neuralgia

Many patients with type 2 diabetes will ultimately require the inclusion of basal insulin in their treatment regimen. Since most people with type 2 diabetes are managed in the community, it is important that primary care providers understand and correctly manage the initiation and titration of basal insulins, and help patients to self-manage insulin injections. Newer, long-acting basal insulins provide greater stability and flexibility than older preparations and improved delivery systems. Basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1–0.2 units/kg/day, then titrated thereafter over several weeks or months, based on patients’ self-measured fasting plasma glucose, to achieve an individualized target (usually 80–130 mg/dL). Through a shared decision-making process, confirmation of appropriate goals and titration methods should be established, including provisions for events that might alter scheduled titration (e.g. travel, dietary change, illness, hospitalization, etc.). Although switching between basal insulins is usually easily accomplished, pharmacokinetic and pharmacodynamic differences between formulations require clinicians to provide explicit guidance to patients. Basal insulin is effective long-term, but overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) should be avoided.Key messagesPrimary care providers often initiate basal insulin for people with type 2 diabetes.Basal insulin is recommended to be initiated at 10 units/day or 0.1–0.2 units/kg/day, and doses must be titrated to agreed fasting plasma glucose goals, usually 80–130 mg/dL. A simple rule is to gradually increase the initial dose by 1 unit per day (NPH, insulin detemir, and glargine 100 units/mL) or 2–4 units once or twice per week (NPH, insulin detemir, glargine 100 and 300 units/mL, and degludec) until FPG levels remain consistently within the target range. If warranted, switching between basal insulins can be done using simple regimens.The dose of basal insulin should be increased as required up to approximately 0.5–1.0 units/kg/day in some cases. Overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) is not recommended; rather re-evaluation of individual therapy, including consideration of more concentrated basal insulin preparations and/or short-acting prandial insulin as well as other glucose-lowering therapies, is suggested. Primary care providers often initiate basal insulin for people with type 2 diabetes. Basal insulin is recommended to be initiated at 10 units/day or 0.1–0.2 units/kg/day, and doses must be titrated to agreed fasting plasma glucose goals, usually 80–130 mg/dL. A simple rule is to gradually increase the initial dose by 1 unit per day (NPH, insulin detemir, and glargine 100 units/mL) or 2–4 units once or twice per week (NPH, insulin detemir, glargine 100 and 300 units/mL, and degludec) until FPG levels remain consistently within the target range. If warranted, switching between basal insulins can be done using simple regimens. The dose of basal insulin should be increased as required up to approximately 0.5–1.0 units/kg/day in some cases. Overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) is not recommended; rather re-evaluation of individual therapy, including consideration of more concentrated basal insulin preparations and/or short-acting prandial insulin as well as other glucose-lowering therapies, is suggested.

Objective: Diabetes is a prevalent and growing problem in the United States (U.S.); primary care physicians need to be prepared to initiate and progressively advance treatment. The objective of thi...

To consolidate the evidence from randomized controlled trials evaluating the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) as add-on to basal insulin therapy in type 2 diabetes (T2D) patients.We searched the EMBASE® and NCBI PubMed (Medline) databases and relevant congress abstracts for randomized controlled trials evaluating the efficacy and safety of GLP-1 RAs as add-on to basal insulin compared with basal insulin with or without rapid-acting insulin (RAI) through 23 May 2016. The pooled data were analyzed using a random-effects meta-analysis model. A subanalysis was performed for trials investigating basal insulin plus GLP-1 RAs versus basal insulin plus RAI.Of the 2617 retrieved records, 19 randomized controlled trials enrolling 7,053 patients with T2D were included. Compared with basal insulin ± RAI, reduction in glycated hemoglobin (HbA1c) from baseline (difference in means: -0.48% [95% confidence interval (CI), -0.67 to -0.30]; p 0.0001) and weight loss (-2.60 kg [95% CI, -3.32 to -1.89]; p 0.0001) were significantly greater with basal insulin plus GLP-1 RA. The subanalysis similarly showed significant results for change in HbA1c from baseline and for weight loss, as well as a significantly lower risk of symptomatic hypoglycemia in patients treated with basal insulin plus GLP-1 RA versus basal insulin plus RAI (odds ratio, 0.52 [95% CI, 0.42 to 0.64]; p 0.0001).Addition of GLP-1 RA to basal insulin provided improved glycemic control, led to weight reduction and similar hypoglycemia rates versus an intensified insulin strategy; however, symptomatic hypoglycemia rates were significantly lower when compared with a basal insulin plus RAI.

Neurogenic orthostatic hypotension (nOH) is common in patients with neurodegenerative disorders such as Parkinson’s disease, multiple system atrophy, pure autonomic failure, dementia with Lewy bodies, and peripheral neuropathies including amyloid or diabetic neuropathy. Due to the frequency of nOH in the aging population, clinicians need to be well informed about its diagnosis and management. To date, studies of nOH have used different outcome measures and various methods of diagnosis, thereby preventing the generation of evidence-based guidelines to direct clinicians towards ‘best practices’ when treating patients with nOH and associated supine hypertension. To address these issues, the American Autonomic Society and the National Parkinson Foundation initiated a project to develop a statement of recommendations beginning with a consensus panel meeting in Boston on November 7, 2015, with continued communications and contributions to the recommendations through October of 2016. This paper summarizes the panel members’ discussions held during the initial meeting along with continued deliberations among the panel members and provides essential recommendations based upon best available evidence as well as expert opinion for the (1) screening, (2) diagnosis, (3) treatment of nOH, and (4) diagnosis and treatment of associated supine hypertension. Electronic supplementary material The online version of this article (doi:10.1007/s00415-016-8375-x) contains supplementary material, which is available to authorized users.

Despite substantive evidence documenting the efficacy of the Mediterranean diet to reduce cardiovascular events, underutilization is common. An overview of the data set supporting the role of the Mediterranean diet as confirmed in both observational and interventional trials should stimulate greater clinician interest in the diet. Additionally, the availability of patient-friendly tools that enable prompt and easy adoption of the Mediterranean diet, that are able to be used by clinicians who claim no special expertise in diet knowledge, should simplify the path to successful dietary change. A large recently published (2018) prospective study of the Mediterranean diet for primary prevention of cardiovascular events confirmed that compared to control, Mediterranean diet is associated with reduced risk for cardiovascular events in high risk patients. Of the tools available to clinicians that might reduce cardiovascular risk, dietary intervention is the one least utilized. The evidence supports the value of dietary intervention with the Mediterranean diet, and methods to effectively employ it within the confines of typical office practice are readily at hand.

Determining what treatment options the patient's insurance will cover and considering the patient's out-of-pocket costs are important actions to be taken while collaborating with the patient and other team members and during the development and implementation of the treatment plan. Reimbursement is available to PCPs for some obesity-related services.

The term 'white coat' hypertension (WC-HTN) is intended to reflect the situation in which measurement of blood pressure (BP) by a health professional (often a physician in a white coat) in an office setting is found to be elevated in comparison with BP measured by a more consistent and less error-prone method such as ambulatory BP monitoring (ABPM), or home BP monitoring (HBPM). Office BP (also sometimes called 'casual BP') has formed the basis of clinical trials that confirm meaningful reductions in MI (25 %), stroke (40 %), and heart failure (50 %) with pharmacotherapy. Nonetheless, within clinical trials, a substantial minority of patients have been determined to have WC-HTN, for which treatment is not known to be of benefit, and is hence not indicated. Clinicians continue to have a good deal of uncertainty about the definition, consequences, course, and best management of WC-HTN. The intention of this communication is to address the top priority questions about WC-HTN to enable clinicians to become more confident in its identification and management.

Osteoarthritis (OA) is the most common debilitating joint disease worldwide. Clinicians have many therapeutic modalities and prescription medications in their arsenals to treat chronic inflammatory pain. However, as patients age, and develop numerous comorbidities, the most common, and often most effective pharmacologic treatment for OA, nonsteroidal anti-inflammatory drugs (NSAIDs), becomes problematic in that it may exacerbate or even cause cardiovascular, renal, and/or gastrointestinal pathology. This paper reviews the metabolism of arachidonic acid as it relates to the clinical treatment of inflammation, and explores a novel botanical therapy, flavocoxid, that has shown equal efficacy to naproxen in treating pain associated with mild to moderate OA of the knee. Flavocoxid has demonstrated balanced inhibition of the three primary enzymes responsible for processing AA, cyclooxygenases 1 and 2, and 5-lipoxygenase. Researchers have proposed that balanced inhibition of AA metabolism offers the prom...

Albuminuria is an important risk marker for adverse cardiovascular (CV) and renal outcomes and mortality. The relationship between albuminuria and risk is continuous and linear, like that of blood pressure and cardiovascular risk. Evidence now supports increased risk even at levels traditionally considered within normal limits. In high-risk patients, routine annual screening can detect changes in urine albumin excretion and improve the timely identification of albuminuria, and therefore should be considered in patients with diabetes, hypertension, and chronic kidney disease. Preferred simple screening methods appropriate for use in the primary care setting include microalbumin-specific dipsticks and urinary albumin:creatinine ratio determination (from a spot urine sample). Cornerstones of albuminuria treatment include risk factor management, ongoing monitoring, and, in patients with hypertension, chronic kidney disease, or diabetes, the use of renin-angiotensin-aldosterone system (RAAS)-blocking agents. Both angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have demonstrated utility in this regard; data from studies of direct renin inhibition are promising. The combined use of an ACE inhibitor and ARB was once considered a viable option for the treatment of albuminuria; however, results of the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) raised important questions regarding the benefits and limitations of dual RAAS blockade. Ongoing studies should provide important insight into the effects of this approach on renal outcomes.

Successful management of type 2 diabetes mellitus (T2DM) requires attention to additional conditions often associated with hyperglycemia including overweight or obesity, dyslipidemia and hypertension, as each has some relationship with microvascular or macrovascular complications. Because control of cardiovascular risk factors is as important as glucose control in T2DM, these risk factors need to be addressed, and it is critical that antidiabetes medications do not exacerbate these risk factors. A patient-centered approach to treatment in which clinicians maximize patient involvement in the selection of antidiabetes therapy may lead to increased adherence and improved clinical outcomes. The incretin hormones, which include glucagon-like peptide–1 (GLP-1), are involved in glucoregulation and have become an important focus of T2DM research and treatment. Incretin-based therapies, such as the glucagon-like peptide-1 receptor agonists and the dipeptidyl peptidase–IV inhibitors, have shown beneficial effects on hyperglycemia, weight, blood pressure and lipids with a low incidence of hypoglycemia.

Good control of diabetes provides meaningful microvascular risk reduction; yet, patients with type 2 diabetes mellitus commonly languish at unsatisfactory levels of glycated hemoglobin (HbA1c) for protracted periods. A variety of factors contribute to this clinical inertia, as clinicians tend to be too conservative in their treatment of patients who are not achieving glycemic control. Available clinical data suggest the near-maximal blood glucose reduction achievable with use of most antidiabetic agents typically occurs within several weeks of treatment initiation. Based on this time course of action, we propose that optimal glycemic control can be attained within 180 days of treatment initiation by advancing antihyperglycemic therapy more rapidly than typical current practice. Our approach builds on current recommendations, though it seeks to redefine standard management of type 2 diabetes by placing greater emphasis on the timing of treatment intensification. We recommend the total period patients spend with uncontrolled hyperglycemia be minimized by shortening the number of steps along the treatment intensification ladder. This can be achieved by establishing combination therapy early in cases where baseline HbA1c levels are markedly elevated, including the prompt addition of basal insulin therapy when it becomes apparent that oral agents alone are unlikely to attain glycemic goals.

Three issues related to the management of acute musculoskeletal pain in the ambulatory care setting deserve more attention than they currently receive: pain assessment, the degree of diagnostic specificity needed to select treatment, and gaps in the care that clinicians need to consider. This article describes several pain assessment instruments and explains why they are appropriate in the acute care setting. It also reviews several reports demonstrating that most patients with acute musculoskeletal pain, particularly low back pain, cannot be given a definitive pathoanatomical diagnosis. Therefore, categorizing the pain as mechanical or secondary to underlying causes is sufficient to select and institute treatment. Gaps in care, such as the need for increased patient education, accurate information to dispel misconceptions about therapy, and additional safety and efficacy data about drugs used to treat acute musculoskeletal pain, are also addressed.

Since its first FDA approval in 2004, duloxetine has been taken by more than 5 million patients. A small fraction of patients treated with duloxetine develop elevations in liver enzymes, which generally resolve spontaneously without any change in treatment. Very rare cases (estimated 1-2 per 100,000 exposures) of idiosyncratic hepatic toxicity have been reported in patients taking duloxetine, particularly in those with substantial alcohol use and/or preexisting liver disease. In the context of more than 23,000 patients exposed during clinical trials, and more than 1.5 million patient years of exposure subsequent to product launch, the hepatic risk after exposure to duloxetine appears to be within the range identified for other therapeutic agents. Therefore, it does not warrant hepatic enzyme monitoring. As with any medication, physicians should follow prescribing guidelines and educate patients on the risks and benefits of duloxetine.

Irritable bowel syndrome is a common gastrointestinal disorder with constipation, diarrhea, and mixed subtypes. The diagnosis is generally based on a detailed history utilizing the Rome III criteria. Alarm signals necessitate more extensive diagnostic evaluation. Nonpharmacologic options and over-the-counter remedies (e.g., loperamide) might not be supported by strong evidence, but are often chosen as initial treatment for their safety and tolerability. Psychological interventions may be beneficial. Newer pharmacologic agents such as alosetron, eluxadoline, linaclotide, lubiprostone, and rifaximin are supported by higher quality evidence than older agents such as antispasmodics and laxatives. Patients with IBS commonly report that clinicians offer insufficient empathy and validation of their symptoms. Physicians therefore should strive to improve communication methods that specifically provide such reassurance. Individualizing treatment based on patient values and preferences is essential.

Hypoglycemia is a condition known to disrupt many everyday activities and is associated with increased risks of hospitalization, falls, motor vehicle accidents and mortality. Many patients with diabetes have an increased risk of hypoglycemia due to interventions targeting glycemic control. In these patients, hypoglycemia and fear of hypoglycemia may further reduce adherence to glucose-lowering regimens, contributing to the further aggravation of diabetes-related complications. Avoiding hypoglycemia should be one of the principal goals of any treatment strategies employing agents that can induce hypoglycemia in order to prevent the occurrence of associated symptoms and consequences. The education of patients and their families is an important feature of individualized management strategies in order to prevent, mitigate and treat hypoglycemic episodes. Patients with diabetes need to be made aware of how to recognize the signs of hypoglycemia and of the simple, highly effective steps that they can take to self-manage hypoglycemic episodes. Clinicians should be familiar with the risk factors for hypoglycemia, especially the profiles of the different classes of glucose-lowering medications such as the sulfonylureas and insulin. This article aims to review the risk factors for hypoglycemia and its implications for patients and healthcare systems, and provide practical advice for minimizing the risk of hypoglycemia and its consequences.

Despite a wave of public awareness of erectile dysfunction as a result of Viagra and its successor oral therapies, most men are not discussing issues related to sexuality with health care professionals. Epidemiologic surveys indicate that male sexual dysfunction (MSD) occupies an epidemiologically compelling position. Few doubt that sexual function is an important priority for men throughout their lifespan. The "therapeutic gap" between the frequency with which clinicians currently engage patients in discussions about sexual health and the optimal frequency of such discussions is substantial. Fortunately, readily applicable interviewing tools can allow health care professionals to obtain necessary fundamental information about sexual health and close this therapeutic gap.

Benign prostatic hyperplasia (BPH) is a common disorder in ageing men. Patients with BPH often present with bothersome irritative and obstructive lower urinary tract symptoms -- urgency, frequency, nocturia, feeling of insufficient bladder emptying and weak or intermittent flow. alpha(1)-Blockers are the most frequently prescribed oral medications for the first-line treatment of the symptoms associated with BPH. Alfuzosin is a uroselective alpha(1)-blocker that relaxes the smooth muscle of the bladder neck and prostate gland to alleviate BPH symptoms. A pooled analysis of three phase III trials confirmed that treatment with alfuzosin 10 mg q.d. significantly improves the peak urinary flow rate and symptom severity compared with placebo treatment. Unlike some other alpha(1)-blockers, alfuzosin 10 mg q.d. is associated with a low incidence of sexual and vasodilatory side effects. Based on the clinical trials reviewed, alfuzosin 10 mg q.d. is an effective and well-tolerated treatment for the urinary symptoms associated with BPH.

Chronic pelvic pain (CPP) in women is a common disorder, affecting as many as 15% of adult women, and often provides both a diagnostic and therapeutic challenge. Pain in CPP may originate directly from pelvic organs, or may be referred from more distant tissue sites. A comprehensive medical history and physical examination should include special attention to gynecological, urological, gastrointestinal, psychiatric, myofascial, and neuromuscular systems. The effective management of CPP may involve comprehensive evaluations by specialists, psychologists, and multiple office visits. Physicians should address CPP as a chronic disease. Combining lifestyle modification with other traditional treatments produces better outcomes. Laboratory tests, transvaginal ultrasound, and laparoscopy may identify serious disease or provide significant reassurance to patient. Specific surgical procedures for various conditions and pain relief measures are beneficial in selected patients. A sensitive physician who is willing to spend adequate time and coordinate care with specialists can markedly diminish the suffering of these patients.

Most men who live to middle age and beyond will ultimately develop lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH), and many will also experience sexual dysfunction. Clinical studies indicate that most patients will experience improvement in BPH-related LUTS with alpha-adrenergic blockade or 5alpha-reductase inhibition. Recent studies suggest that alpha-blockers and 5alpha-reductase inhibitors may help to slow the progression of LUTS; 5alpha-reductase inhibitors reduce the need for surgery and complications, such as acute urinary retention. Third-generation alpha-blockers (alfuzosin, tamsulosin) are infrequently associated with cardiovascular side effects, in contrast to their predecessors (doxazosin, terazosin, prazosin). This may provide an advantage for consideration as firstline therapy. alpha-Blocker therapy may also improve sexual functioning, with the exception of ejaculation disorders, predominantly associated with subtypeselective alpha-blockers. By contrast, 5alpha-reductase inhibition is not recommended for men without demonstrable prostatic enlargement, may be associated with a long delay between treatment initiation and LUTS improvement, and is clearly associated with sexual side effects, including decreased libido, ejaculatory dysfunction, and erectile dysfunction. When choosing appropriate pharmacotherapy, the clinician should consider not only the expeditious relief of the presenting symptoms but also the patient's quality of life, including sexual function and potential long-term outcomes, such as acute urinary retention and the need for surgical intervention.

Robert A. Kloner, MD, PhD (Los Angeles, California, USA): In his editorial comment on an article by Morales et al, in 1998, Dr. Francesco Montorsi was referring to sildenafil when it arrived on the market, but his point is still relevant. Many clinicians—specialists and generalists alike—will have to become familiar with a new class of agents generally termed phosphodiesterase 5 (PDE5) inhibitors. Accordingly, we convened a group of clinicians representing several specialties to discuss the implications of these agents. This roundtable includes the views of 3 cardiologists (Drs. Brindis, Cheitlin, and myself), 2 primary care physicians (Drs. Kuritzky and Miller), 1 urologist (Dr. Padma-Nathan), and 1 psychologist (Dr. Rosen).

Arthritis is a growing health concern in the US with approximately 70 million Americans currently affected. This figure will inevitably rise as the population ages. The pain and decreased mobility associated with arthritis have a significant impact on quality of life and because patients with arthritis are less active than the general population, they are at risk of additional conditions such as obesity, heart disease, diabetes, and hypertension. There are currently no disease modifying osteoarthritis (OA) drugs available; therefore anti-inflammatory, and/or analgesic medications such as acetaminophen and NSAIDs and simple analgesics form the mainstay of treatment. Coxibs may be preferred to traditional NSAIDs because of their improved gastrointestinal (GI ) safety and tolerability profile. The use of topical agents may also be beneficial in some patients. In rheumatoid arthritis (RA) where disease modifying drugs (DMARDs) are available, anti-inflammatory agents such as NSAIDs and coxibs are used as adjuncts to disease modifying therapy. However, patients with RA are at increased risk of NSAID-related GI injury, particularly if they are also on corticosteroid medication. Pharmacological treatment of both RA and OA should be combined with appropriate nonpharmacological modalities such as patient education, exercise programs, and joint motion and strengthening exercises. Such activities may delay joint degradation and help maintain physical function.

Polycystic ovary syndrome is a common premenopausal endocrino-metabolic disorder. In addition to hyperandrogenism, menstrual abnormalities, ovulatory disturbances and infertility, insulin resistance, dyslipidemia, and obesity may eventuate in long-term cardiovascular consequences.

Diabetes is a major and growing health problem in the US. An incredible array of different oral medications is now on the market. Clinicians should understand all these new medications and in which clinical picture they will work best.

Most antihyperglycemic agents available for the treatment of type 2 diabetes mellitus (T2DM) have insulin-dependent mechanisms of action; that is, they either stimulate insulin production (sulfonylureas, glinides, incretin mimetics, dipeptidyl peptidase-4 inhibitors), improve insulin sensitivity (thiazolidinediones, biguanides), or directly augment endogenous insulin (basal and prandial insulins). As β-cell function deteriorates, combination therapy is usually needed to effectively control glycemia. Moreover, some antihyperglycemic agents are associated with adverse effects, such as weight gain and hypoglycemia. A novel approach for treating T2DM is to inhibit renal glucose reabsorption through inhibition of sodium glucose co-transporter 2 (SGLT2), which is responsible for the majority of glucose reabsorption in the renal proximal tubule. By reducing the renal capacity to reabsorb filtered glucose, SGLT2 inhibitors increase excretion of excess glucose in urine, thereby decreasing plasma glucose concentration. Thus, although glucosuria is often viewed as an indicator of systemic hyperglycemia, this perception needs to be modified in patients treated with SGLT2 inhibitors where glucosuria is an indicator of the desired treatment effect. Currently, 2 SGLT2 inhibitors, canagliflozin and dapagliflozin, are approved in the United States for the treatment of patients with T2DM; other SGLT2 inhibitors are in various stages of clinical development. Clinical studies in patients with T2DM on a variety of background diabetes treatments have demonstrated the efficacy of canagliflozin and dapagliflozin in improving glycemic control and reducing body weight and blood pressure. Canagliflozin and dapagliflozin are generally well tolerated, with a low risk of hypoglycemia when not used in combination with insulin and/or sulfonylurea. Higher incidences of genital mycotic infections and adverse events related to osmotic diuresis and volume depletion were observed with both agents; they were generally mild or moderate and infrequently led to study discontinuation. Based on current evidence, SGLT2 inhibitors provide an important new treatment option for patients with T2DM.

Type 2 diabetes (T2D) is an increasingly common endocrine disorder that is characterized by chronic hyperglycemia and tissue compartment abnormalities, including macrovascular and microvascular complications. More than 90% of patients with T2D will be diagnosed and treated in the primary care setting. One of the relatively recent additions to the increasing array of approved antidiabetic medications is the glucagon-like peptide-1 receptor agonist class. Mechanisms of action for glucagon-like peptide-1 receptor agonists include: 1) stimulation of insulin secretion through β-cells, though only when glucose levels are elevated (hence, minimizing risk for hypoglycemia); 2) blunting of glucagon secretion; 3) increased satiety; and 4) decreased rate of release of gastric contents into the small intestine, thereby reducing glycemic load. Recent T2D treatment guidelines encourage individualization of therapy. Many patients still do not achieve optimal glycemic control. Therefore, other treatment options are important.A literature search was performed using PubMed and MEDSCAPE to retrieve abstracts and articles pertinent to topics discussed in this review. Original research articles, reviews, and clinical trial manuscripts were identified based on relevance. Only English language articles were considered. Results In 3 phase 3 registration trials in patients with T2D, once-weekly dulaglutide demonstrated superior efficacy at the primary endpoint to metformin as monotherapy, to sitagliptin as add-on to metformin, and to exenatide twice daily as add-on to metformin and pioglitazone. The safety profile of dulaglutide in these trials is similar to currently available glucagon-like peptide-1 receptor agonists, characterized predominantly by gastrointestinal symptoms (ie, nausea, vomiting, and diarrhea). Based on these results, once-weekly dulaglutide should be a relevant additional treatment option for the management of T2D.

A discussion of primary care issues related to the management of angina in the office setting is warranted because of recent developments. These developments include new pharmacotherapies, recent insights into the pathophysiology of angina, and increased recognition of the role of the diseased endothelium in sequelae of coronary artery disease.

(1999). Improving Management of Type 2 Diabetes Mellitus: 3. Sulfonylureas. Hospital Practice: Vol. 34, No. 12, pp. 129-140.

Hypertension is highly prevalent and remains poorly controlled. The purpose of this study was to evaluate blood pressure (BP) control in patients with uncontrolled hypertension 1 year after referral to a hypertension specialist. A retrospective chart review was performed on 158 patients evaluated by a single hypertension specialist between 2005 and 2010 at the Penn Hypertension Program. Patients were included if they had at least 1 year of follow‐up and had baseline plasma renin activity and plasma aldosterone concentration measured. Drug regimens were adjusted with particular attention to results of renin‐aldosterone profiling. Mean BP of the entire cohort decreased from 149/87 mm Hg to 129/78 mm Hg at 1 year (P

Steps for facilitating management include: 1) identification and referral of patients with a nonmechanical cause of pain, such as cancer or an aortic aneurysm; 2) matching the analgesic agent and the mobilization schedule to the patient's condition and pace of recovery; 3) referring patients whose condition may require surgery; 4) and caring for the remaining patients who have chronic pain.