Meeting Perspectives-Internal Medicine 2007 -The American College of Physicians

May 11, 2007

ACPBy: Mitchell Charap, MD Senior Associate Program Director, NYU Internal Medicine Residency Program

The ACP’s annual session is a bit different from other major annual medical meetings. In general it is an excellent review of the prior year’s literature rather than a forum for breaking news and major announcements. Information that is vital to a practicing internist is reviewed in depth. What follows is a collection of what I found to be the most important and interesting clinical points that I took away from the meeting.

Thyroid disease and Pregnancy: Hypothyroidism in pregnancy is a problem. Children born to mothers with untreated hypothyroidism have lower IQs than children of euthyroid mothers. There is good evidence that thyroid hormone replacement should be increased in hypothyroid pregnant women and the TSH should be monitored frequently.

In J Clin Endocrinol Metab. (2006; 91: 2587-91) the authors studied 984 pregnant women and found 115 to have TPO antibodies with normal TSH (although normal, the TSH levels were higher in the TPO positive group). Half were treated with thyroxine and the others were not treated. Repeat TSH levels were repeated at 20 weeks, 30 weeks, and 3 days post-partum. Miscarriage rates were higher in the TPO positive patients not treated: 13.8 vs. 3.5%. Premature deliveries were higher: 22% vs. 7%

Conclusions: These findings if confirmed by a larger RCT suggest that pregnant women should be screened for autoimmune thyroid disease and those with TPO Ab be treated with thyroxine.

Hs CRP: Indications for Assessing Cardiac Risk: Hs CRP is associated with traditional markers of increased CV risk. The independent role of hs CRP and other inflammatory markers is more controversial. To prove its value as an independent risk factor the JUPITER trial (we already had ASTEROID) is studying the role of statins in patients with high hsCRPs and low/normal lipid profiles. However recruitment in this trial is lagging, the researchers are finding it difficult to find such patients. This problem in recruitment suggests that the JUPITER population may be quite small and further places in doubt the contribution of hs CRP and other inflammatory markers to traditional risk assessment.

STAR *D report(Am J Psychiatry. 2006;106): A very important study of antidepressant therapy conducted by NIMH. 4000 patients at 41 sites (18 general medical settings). There was no placebo control. The conclusions are:

  1. Only 1/3 of patients respond to monotherapy (citalopram). provides important, practical answers. For remission, the mean dose of citalopram (41.8 mg/day) was higher and the mean duration of treatment (47 days with 5.5 visits) was longer than might have been expected on the basis of current clinical practice. This rate and timing of response was approximately the same in specialty care and primary care sites. Who responds? In general, response was best in highly educated, currently employed Caucasian women with few complicating psychiatric or medical disorders. Most important, this study demonstrates that for at least 70% of patients, appropriate treatment with an SSRI is not enough.

  2. Over 50% of patients responding to antidepressants require eight weeks or more of treatment to see benefit.

  3. If monotherapy failed (as it did in 70%), then there were several options which I will discuss next week.