Dragi Weekly No. 268 : COVID (thrombotic disease guidelines, ARB and ACE inhibitors), COPD (GOLD 2020), neuropathic pain, pain tolerability, pernicious anemia, Dreamscape

Hello! Holidays are a good time to rest and break the rhythm in these complicated times. I still hope you're doing well. Lots of things this week, enjoy the reading!

1/ COVID-19

The American College of Cardiology has issued guidelines regarding the thrombotic risk in COVID. For ambulatory patients, measures to prevent a sedentary should be carried out, but prophylactic anticoagulation should not be systematic. It can nevertheless be discussed in patients with risk factors for thrombosis and low risk of bleeding. For hospitalized patients (not in intensive care), prophylactic anticoagulation is recommended (not at intermediate or effective doses). Also no screening for DVT is recommended if D-dimer > 1500 and patient is asymptomatic.

Following the poor study in the NEJM, the Lancet publishes a randomized controlled trial evaluating remdesivir versus placebo in COVID: no clinical improvement at D28 in the whole cohort but may be a faster improvement in patients with symptoms less than 10 days old (and this is not significant...) But it would "work" in an unpublished study according to a communication from Gilead...

A retrospective study published in the NEJM investigated the risk of COVID associated with antihypertensive drugs. When matched on a propensity score, none of the antihypertensive classes, including ACE inhibitors and ARBs, were associated with a significant increase in the risk of COVID or severe COVID.

2/ Pain

Is a Numeric Rating Scale (NRS) a good tool for assessing pain tolerability in chronic pain? In this study, when the NRS was below 4, the pain was tolerable (ok, there it is) but when it was between 4 and 6, 19% of the patients "already" considered it not tolerable. It is from 8 and above that more than 50% of the patients consider it not tolerable, but even then between 30% and 50% of the patients consider it tolerable. So let's just ask patients how they feel rather than deciding what action to take based on a numerical value.

The BMJ  discusses treatments for chronic pain with a focus on pregabalin and gabapentin. They work well on neuropathic pain and are recommended for first-line use. The NNT of pregabalin>600mg/d is about 10 for a 50% reduction in pain with a similar NNH of discontinuation for similar side effects. For gabapentin >1200mg/d, the NNT is rather 6, and the NNH 30. So advantage to gabapentin. To limit premature discontinuation, the authors recommend starting at a low dose and stopping the increase at the onset of symptoms or even lowering the dose. Looking at tricyclics antidepressants have a NNT of 3.6 and serotonin-noradrenaline reuptake inhibitors of 6.4. So gabapentinoids would work less well in the end. Finally, these antiepileptics have proven efficacy in neuropathic pain but not in low back pain, sciatica and migraines

The Cochrane collab has published a review on the efficacy of epidural corticosteroid infiltration in radicular pain. The authors found an immediate benefit of -5 points (/100), and in the medium term (3 months) of -4 points. In short, it is statistically significant but not necessarily clinically relevant.

3/ Cardiovascular disease

A randomized controlled trial of NEJM including more than 1000 patients found non-inferiority of apixaban versus dalteparin in the management of cancer-associated venous thrombosis without increasing the risk of bleeding.

As a reminder, the recommended dual antiaggregation therapy for STE-ACS is aspirin+tigagrelor or prasugrel. In case of stable coronary artery disease with stent: aspirin+clopidogrel. This study compared aspirin + ticagrelor vs aspirin + clopidogrel in NSTE-ACS in patients over 70 years old: no difference on the net clinical benefit, but less bleeding with clopidogrel which seems to be preferable (In France we stayed a lot on clopidogrel, I believe).

4/ Respiratory diseases

The GOLD has updated the COPD guidelines for 2020. I will put below the 2 important figures: the one to determine the initial treatment, and the one to adapt according to the intensity of dyspnea or exacerbations. There is always a tendency to decrease inhaled corticosteroids (especially if repeated pneumonia, eosinophils < 100 or mycobacterial CDTI). The importance of smoking cessation, physical activity, and influenza and pneumococcal vaccination should be noted. It is also necessary to think about looking for co-morbidities (coronary artery disease, depression, GERD, osteoporosis...). In case of exacerbation, the authors recommend :

- B2 short-acting +/- short-acting anticholinergics,

- oral steroids: 40 milligrams for five days, "but should be limited to significant exacerbations."

- antibiotics (amox+ac.clavu or macrolides or tetracycline for 5 to 7 days if sputum is purulent (sensitivity 94%, but specificity 52% for a bacterial cause) associated with increased dyspnea or increased volume of sputum.

5/ Gastro-enterology

Le BMJ talks about  pernicious anemia (1/3 of patients have normocytic anemia with normal B12). It can be suspected in the presence of anaemia, but also in the presence of unexplained symptoms: fatigue, cognitive impairment or concentration disorders, paresthesias (but also alopecia, dyspnoea, palpitations, gastrointestinal disorders, depressive symptomes). Signs of severity are: paresthesia and hyporeflexia, ataxia and loss of muscle strength, dyspnea and peripheral edema, cognitive disorders and depression. The assessment therefore requires a serum B12 test and then serum intrinsic factor antibodies  (In fact, even if B12 is normal, it does not eliminate the diagnosis: holotranscobalamin, methylmalonic acid and homocysteine should be checked before looking for anti IF Ac). Treatment 1000µg of B12, 3 times a week for 2 weeks then once a month.

6/ The game of the month: "Dreamscape"

"Dreamscape" is a visually attractive strategy game that will take you to the world of dreams! Indeed, each player we will call "sleepers", draw cards of various difficulty representing a "dream landscape". You will then have to collect the elements that make it up (water, rock, earth tokens...) to recreate them on your personal board and score points! Also be careful not to take too many nightmare tokens which will disturb your sleep (and reduce your chances of victory...) The mechanics are original, interesting and accessible. In short, a game that I recommend!

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See you soon!

@Dr_Agibus