March 13, 2013

DynaMed EBM Journal Volume 8, Issue 11

DynaMed Weekly Updates

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: March 13, 2013

Expiration Date: March 13, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote EducationCompany and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1210393B


Last week 383 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 263 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Extended Anticoagulation with Apixaban or Dabigatran Reduces Recurrent VTE and Mortality without Increasing Major Bleeding
Reference: N Engl J Med 2013 Feb 21;368(8):699, N Engl J Med 2013 Feb 21;368(8):709 (level 1 [likely reliable] evidence)

Anticoagulation treatment for patients with venous thromboembolisms (VTEs) is generally recommended for at least 3 months (Eur Heart J 2008 Sep;29(18):2276, Chest 2012 Feb;141(2 Suppl):e419S) but there is a high risk of recurrence. Extended treatment decreases the risk of recurrence but can increase the risk of major bleeding (Cochrane Database Syst Rev 2006 Jan 25;(1):CD001367), so the decision concerning how long to continue anticoagulation can be complicated, especially in patients with unprovoked VTE. Two new trials evaluated the safety and efficacy of extended anticoagulation treatment with either apixaban (AMPLIFY-EXT trial) or dabigatran (RE-SONATE trial).

In the AMPLIFY-EXT trial, 2,486 patients with VTE who had already completed 6-12 months of anticoagulation therapy were randomized to apixaban (2.5 mg vs. 5 mg) orally twice daily vs. placebo for an additional 12 months. Previous treatments included warfarin, apixaban, or enoxaparin. All patients were recurrence-free during previous treatment and were eligible for either continuation or cessation of anticoagulation.

Symptomatic or fatal VTE occurred in 1.7% in each apixaban group (2.5 mg and 5 mg doses) and in 8.8% in the placebo group (p < 0.001, NNT 14 for each apixaban dose). There were no significant differences in the rates of major bleeding among groups (0.1-0.2% with apixaban vs. 0.5% with placebo). The higher apixaban dose was associated with an increase in clinically-relevant nonmajor bleeding compared to placebo (4.2% vs. 2.3%, p < 0.05, NNH 52). The difference between the rates of clinically relevant bleeding between the lower dose and placebo (0.7%) was not significant.

In the RE-SONATE trial, 1,353 patients with VTE who had completed 6-18 months of anticoagulation were randomized to dabigatran 150 mg orally twice daily vs. placebo for 6 months. Recurrent or fatal VTE occurred in 0.4% with dabigatran vs. 5.6% with placebo (p < 0.001, NNT 20). Clinically relevant bleeding occurred in 5.3% vs. 1.8% (p = 0.001, NNH 28), but there was no significant difference in the rates of major bleeding. An additional noninferiority trial (RE-MEDY trial) comparing dabigatran to warfarin was reported in the same article. The rates of recurrent or fatal VTE were similar for the 2 active drugs, but dabigatran was associated with reduced risk of clinically-relevant bleeding (5.6% vs. 10.2%, p < 0.001, NNT 22), and with a nonsignificant reduction in major bleeding (0.9% vs. 1.8%, p = 0.06).

Other options for long-term prophylaxis against VTE recurrence include rivaroxaban (N Engl J Med 2010 Dec 23;363(26):2499) and aspirin (N Engl J Med 2012 May 24;366(21):1959). In the absence of head-to-head trials comparing the different possible treatments, the decisions of whether to give additional treatment and which agent to select must be individualized, based on risks for bleeding and risks for recurrence of VTE.

For more information, see the Anticoagulant therapy for venous thromboembolism topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

DynaMed Extras

New Guideline for Acute Otitis Media from American Academy of Pediatrics

The American Academy of Pediatrics (AAP) has just published a new guideline for the diagnosis and management of acute otitis media (AOM) in children (Pediatrics 2013 Mar;131(3):e964). Antibiotics are recommended in children with moderate or severe otalgia, otalgia > 48 hours, fever ≥ 39 degrees C (102.2 degrees F), and in children < 2 years old with bilateral AOM. Either antibiotics or watchful waiting is recommended for children with mild AOM not meeting these criteria. Amoxicillin is the antibiotic of choice in most cases. Alternatives for children with penicillin allergy include cefdinir, cefuroxime, cefpodoxime, and ceftriaxone. The decision to use amoxicillin-clavulanate instead of amoxicillin is now based on the likelihood of resistance rather than the severity of otitis. Most other antibiotic choices are no longer recommended. There is now a recommendation against the use of prophylactic antibiotics in children with recurrent AOM. The guideline suggests offering the option of tympanostomy tubes for recurrent AOM.

For more information, see the Acute otitis media (AOM) topic in DynaMed.

DynaMed Events

American Academy of Neurology (AAN) Annual Meeting, March 16 - 23, 2013
Deputy Editor Cynthia Brown, MD, will be presenting a poster at the 2013 American Academy of Neurology Annual Meeting at the San Diego Convention Center in San Diego, California. The topic of the poster is "Measuring the Rate of Change in Core Evidence and Guidance in Neurology" and will be on display from 7:30am – 12:00pm March 20th.

Visit the American Academy of Neurology website to learn more about the event and for registration information.

Evidence Live 2013, March 25 - 26, 2013
Claire Honeybourne will be presenting a poster on behalf of Editor-in-Chief Brian Alper, MD, MSPH, FAAFP, at the Evidence Live 2013 annual conference. The conference is being held at the University of Oxford in Oxford, UK. The topic of the poster is "How Frequently Does Our Core Evidence and Guidance Change?" Oral presentation and Poster no. 22 will be presented during the 4:00 hour on March 25th.

Visit the Evidence Live website to learn more about the event and for registration information.

American College of Physicians (ACP) Internal Medicine 2013, April 11- 13, 2013
Senior Deputy Editor Larissa Lucas, MD, FACP, and Deputy Editor Sheila Bond, MD, will be attending the American College of Physicians Internal Medicine 2013 conference, held at The Moscone Center in San Francisco, California. Representatives will be available at the DynaMed booth (1402) to discuss peer review, mobile access, and free trial information.

Visit the American College of Physicians website to learn more about the event and for registration information.

If you would like to meet with a DynaMed representative at any of our conferences, please contact us at

New Topics Added to DynaMed this Week

Carbapenem-resistant Enterobacteriaceae (CRE)

Endovascular therapy for acute stroke

Call for Peer Reviews

We are currently seeking reviewers for:

Hereditary hemorrhagic telangiectasia

Tetralogy of Fallot in adults