From the Guidelines
Evidence-Based Medicine (EBM) topics relevant to primary care internal medicine interns include the management of hypertension in adults, specifically the comparison of angiotensin-converting enzyme inhibitors (ACEIs) such as lisinopril 10-40mg daily versus angiotensin receptor blockers (ARBs) like losartan 50-100mg daily, in terms of blood pressure control and cardiovascular outcomes 1.
Key EBM Topics
- Hypertension management: The evaluation of nonpharmacologic and pharmacologic treatment of essential and resistant hypertension, including the use of ACEIs and ARBs, is a crucial EBM topic for primary care internal medicine interns 1.
- Antibiotic treatment duration: The assessment of antibiotic treatment duration for uncomplicated urinary tract infections, such as trimethoprim-sulfamethoxazole 160/800mg twice daily for 3-5 days versus 7-10 days, is another relevant EBM topic.
- Statin therapy: The evaluation of statin therapy, including atorvastatin 10-20mg daily, for primary prevention of cardiovascular disease in patients with elevated low-density lipoprotein cholesterol levels is also a pertinent EBM topic.
Overcoming Clinical Inertia
The adoption of EBM guidelines is crucial in primary care internal medicine, and overcoming clinical inertia is essential to provide optimal patient care 1. Clinical inertia refers to the provider's failure to initiate or intensify treatment despite a clear indication and recognition of the need to do so. Understanding the barriers to provider adherence to clinical practice guidelines and implementing effective interventions to overcome clinical inertia can improve patient outcomes.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Evidence-Based Medicine Topics in Primary Care Internal Medicine
- Hypertension management: The 2014 evidence-based guideline for the management of high blood pressure in adults recommends treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg 2
- Blood pressure thresholds: Many physicians have higher BP thresholds for the diagnosis and treatment of hypertension than the 140/90 mm Hg criterion recommended by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 3
- Evidence-based practice: Integrating evidence-based medicine into resident education is crucial for reducing medical waste, adhering to guidelines, and decreasing morbidity and mortality rates 4
- Nursing case management: Nursing case management may be effective in improving blood pressure control in adults with hypertension, particularly in primary health care settings 5
- Limitations of evidence-based medicine: Despite its achievements, evidence-based medicine has limitations, including a failure to acknowledge the limitations of clinical trials and systematic reviews, an almost exclusive focus on drugs and devices, and an overdependence on commissions for research 6
Key Recommendations
- Treat hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg 2
- Use angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, or thiazide-type diuretics as initial therapy for hypertension 2
- Consider nursing case management as a potential strategy for improving blood pressure control in adults with hypertension 5
Gaps in Evidence
- There is insufficient evidence to support a systolic goal for hypertensive persons younger than 60 years or a diastolic goal for those younger than 30 years 2
- The effectiveness of nursing case management in improving blood pressure control is limited by the heterogeneity of studies and the low or very low level of evidence 5