6 Can't-Miss Guideline Changes for Primary Care

Neil Skolnik, MD


December 24, 2020

This transcript has been edited for clarity.

I'm Dr Neil Skolnik. Today we're going to talk about the most important guideline changes for primary care from 2020, saving the best for last.

Starting with the International Society of Hypertension Guidelines. Grade 1 hypertension is defined as a blood pressure of 140-159/90-99. Remember that the American Heart Association guidelines defined stage 1 hypertension as 130-139/80-89. So now we have a choice of goals. If possible (both guidelines say) we should confirm the diagnosis with out-of-office BP measurements. How about treatment? For high-risk patients with confirmed grade 1 hypertension and high cardiovascular risk, start treatment with pharmacologic therapy. For those at lower cardiovascular risk, first try 3-6 months of lifestyle modification. Then, if the patient is not at goal, begin pharmacologic therapy.

Let's go on and talk about the American College of Cardiology's Expert Consensus Pathway on Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes. Here, those with diabetes and heart failure, diabetic kidney disease, atherosclerotic cardiovascular disease (ASCVD), or at risk for ASCVD should get an SGLT2 inhibitor or a GLP-1 receptor agonist as part of their medical regimen. How about both classes together? The guidelines say that although there have been no clinical trials looking at combining the two drugs for cardiovascular risk reduction, that strategy is reasonable, if clinically indicated.

Let's talk about COPD and the American Thoracic Society's guidelines, Pharmacologic Management of COPD. There have been a lot of new medicines for COPD over the past few years, and this guideline helps clarify their use.

  • For patients with COPD who experience shortness of breath but have not had an exacerbation in the past year, dual bronchodilator therapy with a long-acting muscarinic antagonist (LAMA) and a long-acting beta agonist (LABA) is recommended over monotherapy with either alone.

  • Patients with COPD who have shortness of breath and have had an exacerbation in the past year ought to receive triple therapy with an inhaled corticosteroid plus dual LAMA/LABA therapy because it reduces the risk for future exacerbations.

These are clear, easy-to-implement recommendations.

If we care about COPD, then we care about tobacco use. Let's go over the official American Thoracic Society Guidelines on treatment of tobacco dependence. This one's easy — it's all about varenicline. Varenicline is associated with about 40% better quit rates than either bupropion or a nicotine patch, so it's recommended over either of those medications. Dual therapy with varenicline and nicotine replacement therapy works better than varenicline alone, so consider combination therapy.

Our next guideline is the CDC's, about treatment of latent TB. The bottom line here: INH is out and rifampin is in. For 20 years we've been treating latent TB with 9 months of INH. Now, based on efficacy (same as the old regimens), ease (the new regimens are much shorter), and safety (less hepatic toxicity), rifamycin-based regimens are recommended specifically, and this makes it easy for us and patients: 4 months of daily rifampin.

Finally, the American Cancer Society's cervical cancer screening guidelines. This is a big change. No more Pap smears. The recommendation for screening is now simply HPV testing every 5 years starting at age 25. Cervical cancer screening can end at age 65 as long as there have been two negative HPV tests in the past 10 years. The guidelines recognize that we are in transition, and until we make the change fully to HPV testing, it's okay to do cytology testing every 3 years, or co-testing with cytology and HPV every 5 years, but we are moving away from cytology.

These are the most important guideline changes for primary care clinicians from 2020.

I'm Neil Skolnik, and this is Medscape.

Neil Skolnik, MD, is a professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University and associate director of the Family Medicine Residency Program at Abington – Jefferson Health. He has published over 350 articles, essays, poems, and op-eds in the medical and nonmedical literature, as well as four medical textbooks and a book of short stories. In addition, he is the host of the American Diabetes Association's monthly Diabetes Core Update podcast. Follow him or direct-message on Twitter: @NeilSkolnik

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