Chief’s Inquiry Corner – 9/28/22

September 28, 2022

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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Bisphosphonates are utilized for treatment of osteoporosis. The optimal duration of therapy however is unknown. Initial data from randomized-control trials suggested their use for between 3-4 years to reduce vertebral and nonvertebral fractures. Later on, two extension trials (FLEX 2006; HORIZON 2007) provided potential evidence for longer term use up to 10 years. In these trials, patients who continued on bisphosphonate therapy after 5 years had fewer clinical fractures. However, concern remained regarding prolonged bisphosphonate therapy and the risk of osteonecrosis of the jaw and atypical femoral fractures. Due to these trials and data, the American Society for Bone and Mineral Research suggested that treatment duration be based on an algorithmic approach based on patient risk. For those at low risk for fractures, no previous recorded fractures, and bone mineral density scoring greater than -2.5, after completing 5 years of bisphosphonate therapy, discontinuation or a drug holiday is suggested. For those at higher risk of fracture, history of prior fracture or fracture while on therapy, continuation of bisphosphonate use with frequent re-assessment for up to 10 years is recommended.

References: Bisphosphonate Therapy
Acute pancreatitis is typically managed with early aggressive fluid hydration. This is largely based on observational data that hypoperfusion can lead to hemoconcentration and ultimately pancreatic necrosis. However, the question of aggressive vs. moderate fluid hydration has not been well studied with randomized controlled trials. Recently, the WATERFALL trial set out to answer this question. This multicenter, randomized controlled trial enrolled patients with acute pancreatitis and assigned them to one of two arms: aggressive resuscitation and moderate hydration. Patients in the aggressive resuscitation arm received a 20ml/kg bolus followed by an infusion rate of 3mL/kg per hour. Those in the moderate resuscitation group received a 10ml/kg bolus followed by an infusion rate of 1.5mL/kg per hour. There was no difference in primary outcome, in-hospital moderately severe or severe pancreatitis, between the two groups. Fluid overload was three times as likely to occur in patients receiving aggressive fluid resuscitation. This recent study suggests that contrary to current guidelines, moderate hydration for patients with acute pancreatitis may be adequate and associated with less severe outcomes than aggressive fluid hydration.

References: Fluid Hydration in Pancreatitis
Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder due to a hypersensitivity reaction to the fungi Aspergillosis fumigatus. It typically occurs in patients with underlying lung disease such as cystic fibrosis and asthma, and presents as recurrent exacerbations often with productive cough. ABPA is underdiagnosed in patients with persistent asthma which can lead to treatment delay. Treatment is centered on symptom control, prevention of pulmonary exacerbations, and reducing inflammation. Given this is a hypersensitivity reaction, glucocorticoids are the mainstay of treatment. Due to lack of clinical trials, optimal dosing is unknown but typically is utilized as a taper for at least 3 months. Antifungals such as itraconazole and voriconazole are typically reserved for those unable to taper glucocorticoids or with severe exacerbations. A prolonged course is typically utilized in this scenario. Omalizumab, a monoclonal antibody that operates against IgE, has also been utilized in the treatment for ABPA, especially for patients with asthma, although definitive data on this is lacking.

References: ABPA Treatment