UpToDate(R) and The Nurse Practitioner are collaborating to present select "What's New" content. UpToDate is an evidence-based, clinical support resource used worldwide by healthcare practitioners to make decisions at the point of care. For complete, current "What's New" content, or to become a subscriber for full content access, visit http://go.uptodate.com/np. "What's New" is free for all medical professionals.
Family Medicine - Adult General Internal Medicine
Prevalence of chronic pain in the United States (May 2023)
Chronic pain is one of the most common reasons that patients seek medical attention and results in high personal and economic costs. A recent Centers for Disease Control and Prevention report estimated that 21 percent (over 51 million) of adults in the United States had chronic pain in 2021 and 7 percent (17 million) had high-impact chronic pain (chronic pain that results in substantial restriction of daily activities).2 The report also noted a high prevalence among certain populations. For example, over 50 percent of adults with disabilities or poor general health had chronic pain, and at least one-third of these individuals had high-impact chronic pain. The information in this report can inform strategies addressing evaluation and treatment of chronic pain in the United States.
Family Medicine - Adult Neurology and Psychiatry
Atogepant for chronic migraine prevention (May 2023)
The first oral calcitonin gene-related peptide (CGRP) antagonist has been approved by the US Food and Drug Administration (FDA) for the indication of chronic migraine prevention.3 In trial data submitted to the FDA but not yet published, atogepant 60 mg once daily or 30 mg twice daily reduced mean monthly headache days more than placebo (-7.3 and -7.1 versus -4.6 days) in 775 patients with chronic migraine.4 The proportion of responders (>=50 percent reduction in headache days per month) was also higher with atogepant (41 and 43 versus 26 percent). UpToDate suggests CGRP antagonists such as atogepant as second-line preventive therapy for patients who do not respond to or tolerate first-line therapy.
Dermatology - Other Dermatology
Methotrexate and prednisone for severe alopecia areata (April 2023)
The efficacy of methotrexate (MTX) for treating refractory alopecia areata is unclear. In a two-step randomized trial that compared MTX alone with MTX plus prednisone, 89 adults with alopecia universalis (n = 88) or alopecia totalis (n = 1) were randomized to oral MTX or placebo for six months followed by rerandomization for patients who had less than 25 percent hair regrowth to MTX alone or MTX plus prednisone.5 All but four patients required rerandomization. At month 12, 7 of 35 patients treated with both MTX and prednisone and 1 patient treated with MTX alone achieved complete or almost complete hair regrowth. No severe treatment-related adverse events occurred with either drug regimen. Although the study was limited by a high drop-out rate (34 percent), the findings suggest benefit of combination therapy with MTX and prednisone in a subset of patients with severe alopecia areata.
Cardiovascular Medicine - Heart Failure
Use of an algorithm to determine venue of care in patients with heart failure (April 2023)
In patients with heart failure (HF) who present to the emergency department, the decision to discharge or admit is often determined on a case-by-case basis. In a recent trial that included nearly 5500 patients with HF who were randomly assigned to triage with a decision-support algorithm (ie, triage to home- or hospital-based management based on risk of readmission) or usual care, those in the decision-support group had a lower risk of death or rehospitalization within 30 days.1 The largest differences in management occurred in high-risk patients who were more likely to be admitted in the decision-support group. In patients with HF who present to the emergency department for evaluation, the decision to discharge or admit may be improved with the use of a decision-support algorithm.
1. Lee DS, Straus SE, Farkouh ME, et al Trial of an Intervention to Improve Acute Heart Failure Outcomes. N Engl J Med. 2023;388(1):22. Epub 2022 Nov 5. [Context Link]
2. Rikard SM, Strahan AE, Schmit KM, Guy GP Jr. Chronic Pain Among Adults - United States, 2019-2021. MMWR Morb Mortal Wkly Rep. 2023;72(15):379. Epub 2023 Apr 14. [Context Link]
3. https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/215206s004lbl.pdf. [Context Link]
4. https://clinicaltrials.gov/ct2/show/NCT03855137 (Accessed on April 24, 2023). [Context Link]
5. Joly P, Lafon A, Houivet E, et al Efficacy of Methotrexate Alone vs Methotrexate Plus Low-Dose Prednisone in Patients With Alopecia Areata Totalis or Universalis: A 2-Step Double-Blind Randomized Clinical Trial. JAMA Dermatol. 2023;159(4):403. [Context Link]
Disclaimer: This content is provided for reference purposes only and represents a portion of the UpToDate topic. Readers should not rely on the content or any information cited here as being applicable to specific patient circumstances. All topics are updated as new evidence becomes available and our peer review process is complete.