Treatments in Specific Populations – Family Medicine

A large percentage of questions on the board exams are based on treatment interventions, as an appropriate treatment is what a patient seeks from a physician. Three major facets of treatment are tested on board exams:

• Treatment algorithms
• Treatments for specific variants of disease and patients belonging to specific populations
• Details regarding particular treatment interventions

This post focuses on selecting the appropriate treatment intervention based on a patient’s specific variant of the disease or the patient’s specific population. Board exams test your ability to know which treatment options are suitable for which population of patients and for which forms of the disease. Such exam questions are generally based on diseases that have well-recognized treatment guidelines.

For instance, in patients with diabetes who also have chronic kidney disease (CKD), glipizide has been recognized as the sulfonylurea of choice. This is because it undergoes hepatic metabolism, and a decrease in the estimated GFR (eGFR) does not affect its clearance and elimination half-life. Therefore, dose adjustments of glipizide are not required (National Kidney Foundation KDOQI clinical practice guideline for diabetes and CKD: 2012 update).

Consider another example; propylthiouracil (PTU) is the recommended antithyroid drug for the treatment of Grave’s disease in pregnant women who are in the first trimester. As compared to propylthiouracil (PTU), methimazole (MMI) has been found to be related to an increased risk of birth defects and should, therefore, be avoided in this specific patient population (Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum, 2017).

Example Exam Question from Family Medicine

Question: A 26-year-old G1P0 woman at 18-weeks of gestation presents to her primary care physician along with her husband, who has been having flu-like symptoms for the last 24 hours. A nasopharyngeal swab is performed on the husband and is found to be positive for influenza. The woman, however, is healthy and shows no signs or symptoms of influenza infection. Which of the following may be the best course of action for this pregnant woman?

1. Administer influenza vaccination
2. Start oseltamivir
3. Start baloxavir
4. Start amoxicillin
5. No treatment is required at this point

Question Explanation

Post-exposure prophylaxis for influenza is not routinely recommended by the Centers for Disease Control and Prevention (CDC). However, due to the increased risk of morbidity and mortality in pregnant and postpartum patients, both the CDC and the ACOG (American College of Obstetricians and Gynecologists) recommend post-exposure antiviral prophylaxis for pregnant women, and for women who are up to two weeks postpartum, who have had close contact with an infectious individual. Oseltamivir 75 mg for a period of 7-10 days is recommended for prophylaxis. Inhaled zanamivir may be used in case of unavailability of oseltamivir. The patients should be counseled to seek immediate evaluation if they develop symptoms of influenza infection such as fever >100^o F along with shortness of breath, chest pain, or syncope.

Let’s review the other options: The influenza vaccination is an essential component of the pre-pregnancy, prenatal, and postpartum care. However, administering the vaccination after exposure may not be the best intervention for preventing the disease. Baloxavir is not recommended for use in pregnant patients due to unavailability of efficacy or safety data. Amoxicillin is an antibiotic and would not be beneficial for the prophylaxis of influenza infection.

 Sources:

Influenza vaccination during pregnancy. ACOG Committee Opinion No. 732. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e109–14.

Assessment and treatment of pregnant women with suspected or confirmed influenza. ACOG Committee Opinion No. 753. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e169–73.

Centers for Disease Control and Prevention. Influenza antiviral medications: summary for clinicians. Atlanta (GA): CDC; 2018. Available at: https://www.cdc.gov/flu/pdf/professionals/antivirals/antiviral-summary-clinician.pdf.

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