Arefa MD's Morning Report: Digital Rectal Exams, Weight Loss Medications, Skipping BP Meds

Arefa Cassoobhoy, MD, MPH


September 23, 2016

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Hello. I'm Dr Arefa Cassoobhoy, a practicing internist and a medical editor for Medscape and WebMD. Welcome to our weekly brief on recent medical news and findings.

Is the Digital Rectal Exam Necessary All the Time?

Our first study confirms that the digital rectal exam (DRE) is not necessary as a first-line screening test for prostate cancer. In the nationwide Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial involving 38,340 men, researchers found that the exam would need to be performed in almost 1400 men with normal prostate-specific antigen (PSA) levels in order to detect a single case of clinically significant prostate cancer. The American Urological Association (AUA) says it may be useful in men with an elevated PSA as a secondary test.

Cutting back on use of DRE for screening purposes could be good news for many. The discomfort and embarrassment associated with the exam might deter some men from being tested for prostate cancer.

So, while PSA testing guidelines vary, you can feel comfortable that the US Preventive Services Task Force, the AUA, and the American Cancer Society all do not require the DRE for primary screening for prostate cancer.

Prescribing Antiobesity Medications

Obese Americans are being dramatically undertreated. Previous studies in the United States estimate that 116 million adults[1] could benefit from antiobesity pharmacotherapy, yet only about 2% are actually being treated with the drugs.

Now, compare that with how diabetes is treated. This retrospective analysis found that 15 times more diabetes drugs than weight loss drugs are prescribed in the United States, and that didn't include insulin. The new SGLT2 inhibitors for diabetes have been adopted at a much faster rate than the newer antiobesity medications, though all entered the market around the same time. Those newer agents include lorcaserin (Belviq®), combination phentermine/topiramate (Qsymia®), and combination naltrexone/bupropion (Contrave®).

Of course, it should be noted that SGLT2 inhibitors can result in weight loss, which may contribute to their popularity.

The researchers acknowledge that there may be a reluctance to use weight loss medications. The reasons include questions about long-term safety and insurance reimbursement. And clinicians may hesitate to look at obesity as a chronic disease that needs treatment beyond diet and exercise. Plus, some doctors don't have the training to comfortably prescribe the drugs.

Is Your Patient Really Taking That Antihypertensive?

And finally, if you think your patient doesn't take his blood pressure meds daily, you're probably right.

The Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services report that more than a quarter of Medicare patients with hypertension were taking their high blood pressure medications less than 80% of the time. That's about 5 million individuals.

One thing that influenced compliance was the type of medication used. Nonadherence was highest with diuretics and better with combination pills.

So the next time you're with a patient struggling to get his blood pressure under control, ask him if he's taking his meds every day. You may be able to simplify the blood pressure medication regimen or address another issue and improve compliance.

For Medscape and WebMD, I'm Dr Arefa Cassoobhoy.

Follow Dr Cassoobhoy at @ArefaMD


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