Compounded pain creams no better than placebo

1. Compounded pain creams no better than placebo for pain relief

Abstract: http://annals.org/aim/article/doi/10.7326/M18-2736

URLs go live when the embargo lifts

Compounded pain creams were no better than placebo creams for relieving localized pain. Their lack of efficacy and relatively high cost compared with approved compounds should curtail use. Results from a randomized controlled trial are published in Annals of Internal Medicine.

Because of the limited effectiveness of available treatments for chronic pain, and concerns about side effects, particularly for opioids, compound pain creams have been heavily marketed to practitioners, without data to support their use. The conceptual appeal for them is that they are essentially devoid of side effects because they don't diffuse into the central nervous system. However, the site of action for most of these drugs to exert their pain-relieving effects is the central nervous system.

Researchers from Walter Reed National Military Medical Center assigned 399 patients with localized pain characterized as neuropathic (i.e. from nerve damage, n=133), nociceptive (i.e. from non-nerve tissue injury, n=133), or mixed (n=133) to receive either a pain cream compounded for their type of pain or a placebo cream. The compounded pain creams included drugs that were FDA-approved or commonly used to treat the different pain conditions, such as muscle relaxants and non-steroidal anti-inflammatory drugs for nociceptive pain and anticonvulsants for nerve pain. At one month after treatment, the researchers found no significant differences between the real pain creams and placebo groups.

According to the researchers, the small benefits that favored the real creams could be explained by the few drugs that exert their effects via the peripheral nervous system. Compounded pain creams were no better than these drugs, but are exponentially more expensive. Based on these findings, the authors say that compounded pain creams should not be routinely used to treat pain.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Steven Cohen, MD, please contact Marin Hedin at mhedin2@jhmi.edu.

2. New ACIP Adult Immunization Schedule recommends changes to flu, hepatitis A, and hepatitis B vaccinations

The ACIP adds homelessness as a risk factor for hepatitis A

Abstract: http://annals.org/aim/article/doi/10.7326/M18-3700

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The Advisory Committee on Immunization Practices (ACIP) released its 2019 Recommended Immunization Schedule for adults with changes to the administration of the influenza, hepatitis A, and hepatitis B vaccines. The schedule, published in Annals of Internal Medicine, has undergone a complete makeover, with revised content, format, and graphics to make it easier to follow.

In June 2018, the ACIP updated recommendations on the use of live attenuated influenza vaccine (LAIV) after 2 influenza seasons (2016-2017 and 2017-2018) during which use of LAIV was not recommended in the United States. For the 2018-2019 season, any licensed influenza vaccine, including FluMist, that is appropriate for the age and health status of the patient may be used.

For hepatitis A, the ACIP recommends adding homelessness as an indication for routine hepatitis A vaccination with a 2-dose series of single-antigen hepatitis A vaccine or a 3-dose series of combination hepatitis A and B vaccine. Other high-risk individuals that should receive routine vaccination include persons with chronic liver disease or clotting factor disorders, travelers in countries with high or intermediate hepatitis A endemicity, persons with close personal contact with an international adoptee in the first 60 days after arrival from a country with high hepatitis A endemicity, men who have sex with men, persons who use injection or noninjection drugs, and persons who work with hepatitis A virus in a laboratory or nonhuman primates infected with the virus. As for hepatitis B vaccine, the ACIP now recommends use of the newly-approved single-antigen recombinant hepatitis B vaccine, Heplisav-B, for prevention of hepatitis B virus infection in adults aged 18 or older, except for in pregnant women. It contains a novel adjuvant and has benefit of more rapid dosing schedule.

While the new schedule is clean and streamlined for ease of reference, physicians should pay careful attention to the details found in the vaccine notes footnotes. The vaccine notes footnotes clarify who needs what vaccine, when, and at what dose.

The complete schedule, including vaccine notes footnote changes, is being simultaneously published in Annals of Internal Medicine and on the Centers for Disease Control and Prevention (CDC) web site. The CDC's ACIP is comprised of the American College of Physicians (ACP) and 16 other medical societies representing various medical practice areas. Each year, the ACIP reviews the CDC's Recommended Adult Immunization Schedule to ensure the schedule reflects current clinical recommendations for licensed vaccines. The recommendations are intended to guide physicians and other clinicians about the appropriate vaccines for their adult patients.

Note: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To interview ACIP representative and former ACP president, Sandra Adamson Fryhofer, MD, MACP, please contact Steve Majewski at smajewski@acponline.org.

3. Genetic testing could be needed for some patients getting organs from a sibling

Abstract: http://annals.org/aim/article/doi/10.7326/L18-0625

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Patients with an autosomal dominant disorder who are receiving organs from a sibling may need genetic testing. A case report published in Annals of Internal Medicine shows that recurrence of acute intermittent porphyria (AIP) is possible after liver transplant.

Clinicians from Massachusetts General Hospital/Harvard Medical School evaluated the case of a 59-year-old woman with AIP who had undergone a liver transplant, which was supposed to be curative. After doing well for 4 years after her transplant, with no evidence of porphyria, the patient began showing symptoms of AIP and biochemical testing confirmed the diagnosis. This is the first case published of a patient with AIP recurring after liver transplantation. According to the authors, this case shows that transplantation of a liver from a person with AIP may result in porphyria in the organ recipient. They suggest that genetic testing of sibling donors should be strongly considered in patients receiving solid organ transplants for autosomal dominant diseases and consideration should be given to awarding MELD exception points to patients with severe acute porphyrias.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Hanny Al-Samkari, MD, please contact him directly at alsamkarih@gmail.com.

4. Annals Graphic Medicine introduces two new regular monthly features

Annals partners with two physician artists to deliver "Dr. Mom" and "Progress Notes" every month

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0058

Editorial: http://annals.org/aim/article/doi/10.7326/M18-3466 URLs go live when the embargo lifts

Annals of Internal Medicine announced today that the journal will now include regular monthly Annals Graphic Medicine features: "Dr. Mom" by physician artist Grace Farris, MD, and "Progress Notes" by physician artist Michael Natter, MD. Drs. Farris and Natter have both been very popular contributors to Annals Graphic Medicine.

New installments of "Dr. Mom" will be published in the first Tuesday of the month and "Progress Notes" will be published on the third Tuesday. Annals will continue to publish new pieces from a variety of authors on the second Tuesday of each month. Annals Graphic Medicine content is free to the public. Visit http://www.annals.org/graphicmedicine to see the complete collection.

About Annals Graphic Medicine

Annals Graphic Medicine brings together original graphic narratives, comics, animation, and other creative forms by those who provide or receive health care. They address medically relevant topics--be they poignant, thought-provoking, or just plain entertaining. Launched in 2015, the series has included single-image artwork; multipaneled sequential stories; and videos from clinicians, patients, and caregivers.

Media contact: To interview an Annals editor about this feature, please contact Angela Collom at acollom@acponline.org.

Also New in this issue:

How Would You Treat This Patient With Gallstone Pancreatitis? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Anjala Tess, MD; Steven D. Freedman, MD; Tara Kent, MD; and Howard Libman, MD

Beyond the Guidelines

Abstract: http://annals.org/aim/article/doi/10.7326/M18-3536

Recognizing the Potential for Overdiagnosis: Are High-Sensitivity Cardiac Troponin Assays an Example?

Katy J.L. Bell, MBChB, MMed(Clin Epi), PhD; Jenny Doust, BMBS, PhD; Paul Glasziou, MBBS, PhD; Louise Cullen, MBBS(Hon), PhD; Ian A. Harris, MBBS, MMed(Clin Epi), PhD; Leon Smith, MBBS; Rachelle

Buchbinder, MBBS(Hons), MSc, PhD; and Alexandra Barratt, MBBS, MPH, PhD

Ideas and Opinions

Abstract: http://annals.org/aim/article/doi/10.7326/M18-2645

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