The American College of Physicians (ACP) has issued an update of its clinical practice guideline for the oral pharmacologic treatment of type 2 diabetes (T2D). Evaluated interventions included metformin, thiazolidinediones, sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium–glucose cotransporter-2 (SGLT-2) inhibitors. The guideline serves as an update to the 2012 ACP guideline and provides clinical recommendations on the topic, including:

• ACP recommends that clinicians prescribe metformin to patients with type 2 diabetes when pharmacologic therapy is needed to improve glycemic control. (Grade: strong recommendation; moderate-quality evidence)
• ACP recommends that clinicians consider adding either a sulfonylurea, a thiazolidinedione, an SGLT-2 inhibitor, or a DPP-4 inhibitor to metformin to improve glycemic control when a second oral therapy is considered. (Grade: weak recommendation; moderate-quality evidence.) ACP recommends that clinicians and patients select among medications after discussing benefits, adverse effects, and costs.

References:

1. 2017 American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care. 2017;40(Supplement 1). doi:10.2337/dc17-S001.

The Surviving Sepsis Campaign issued new guidelines on management of sepsis and septic shock last week.

This fourth edition of the guidelines (updating the 2004, 2008, and 2012 editions) was published in Critical Care Medicine (free) and Intensive Care Medicine(subscription required) on Jan. 18. A number of related articles were published in these and other journals.

A viewpoint published by JAMA on Jan. 19, coauthored by a coauthor of the guidelines, summarized some of the most significant changes. Early goal-directed therapy is no longer recommended and is to be replaced by hemodynamic assessment for further fluid administration after the initial fluid bolus, the viewpoint noted. The new guidelines also favor use of dynamic variables to predict fluid responsiveness, the viewpoint noted. The guidelines recommend antibiotic administration as soon as possible, within an hour at most, and offer advice on whether to use combination antibiotic therapy depending on whether patients have sepsis or septic shock, the viewpoint noted. Updated bundles for sepsis care based on the guidelines will be released later this year, according to the viewpoint. 

A guideline synopsis, also in JAMA, highlighted additional recommendations, including that clinicians should assess patients daily for potential de-escalation of antimicrobials and use norepinephrine as the first-choice vasopressor, and that hospitals and health systems should implement programs to improve sepsis care that include sepsis screening. 

A users' guide to the guidelines, written by three guideline coauthors and published in Critical Care Medicine, offered advice for clinicians working to implement the guidelines. In addition to explanatory flowcharts, the guide offered reassurance that “antibiotic administration within an hour of diagnosis of sepsis is a lofty goal of care, judged to be ideal for the patient but not yet standard care” and that sepsis patients “still benefit from the art of medicine, which includes interpretation of data and individualization of treatment.” 

The guidelines were developed by a committee of 55 international experts representing 25 international organizations who were divided up to focus on five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Overall, they developed 93 statements on early management and resuscitation of patients with sepsis or septic shock—32 strong recommendations, 39 weak recommendations, and 18 best-practice statements.

By Amy Orciari Herman

Mortality from cervical cancer is higher than previously believed, particularly among black women, a study in Cancer finds. The analysis excluded women who'd undergone hysterectomy, most of whom would no longer have a cervix, while prior studies included such women and therefore may have underestimated cervical cancer rates.

In the new study, U.S. researchers examined national data on hysterectomy and cervical cancer from 2000 to 2012. An estimated 23% of black women and 21% of white women had undergone hysterectomy. Removing these women from the analyses, the age-standardized rate of cervical cancer mortality among black women was 10.1 per 100,000 population (vs. 5.7 per 100,000 before correction for hysterectomy). The mortality rate among white women was 4.7 per 100,000 (vs. 3.2 before correction). 

Dr. Andrew Kaunitz, editor-in-chief of NEJM Journal Watch Women's Health, commented: "Adolescent girls are already benefitting from deployment of human papillomavirus vaccination; for women beyond vaccination age, encouraging access to cervical cancer screening continues to represent the main prevention strategy for cervical cancer."

Cancer article (Free abstract)

Cancer editorial (Subscription required)

Background: Physician's First Watch coverage of insufficient cervical cancer screening in U.S. (Free)

Two new studies compared the prognostic accuracy of various criteria for identifying patients with sepsis.

Both studies were published in the Jan. 17 JAMA and compared the quick Sequential Organ Failure Assessment (qSOFA) score, which was introduced by the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), with the SOFA score and systemic inflammatory response syndrome (SIRS) criteria.

The first study was conducted in 30 European EDs between May and June 2016. The prospective cohort analysis included 879 patients with suspected infection who had an overall in-hospital mortality rate of 8%. The mortality rate was 3% in patients with a qSOFA <2 compared to 24% in those with a score ≥2. The qSOFA score was better at predicting in-hospital mortality than SIRS or severe sepsis, the study found. The results support the Sepsis-3 recommendations, the study authors wrote, noting that the low mortality rate observed in patients with qSOFA <2 supports the safety of replacing SIRS with qSOFA. They also noted that adding blood lactate levels to qSOFA did not improve prognostication. “This along with other current findings could result in a complete change of the current clinical approach because the severity of sepsis up until now has been assessed in ED patients using lactate levels,” the authors wrote. They did caution that the study was limited by its use of the worst qSOFA score during a patient's entire ED stay,and future research should assess the prognostic value of the score at ED entry. 

The second study was a retrospective cohort analysis of 184,875 patients admitted to ICUs in Australia or New Zealand with an infection-related primary diagnosis. In-hospital mortality was 18.7%, and 55.7% of patients died or had an ICU length of stay of three days or more. During the first 24 hours in the ICU, the SOFA score increased by two or more points in 90.1% of patients, while 86.7% met two or more SIRS criteria, and 54.4% had a qSOFA ≥2. The researchers found that SOFA demonstrated significantly greater discrimination for in-hospital mortality than SIRS or qSOFA, also supporting the Sepsis-3 recommendations. Study authors cautioned that the data used were not primarily collected for the study's purpose, among other limitations. 

An editorial accompanying the studies noted that the ICU study's findings were not surprising. Outside the ICU, based on the other study's results, “qSOFA appears a simple, rapid, inexpensive, and valid way to identify—among patients with suspected infection—those at a higher risk of having or developing sepsis,” the editorialists wrote. They did note limitations, including that 14% of patients recruited in the ED study were excluded due to missing values, and called for further research on qSOFA in lower-income settings and when used longitudinally.