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CME

Credits

Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: April 8, 2015
Expiration Date: April 8, 2016

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 above.

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 Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive 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

Disclosures

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 providership of Antidote Education Company 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: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. 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(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. Program ID: 1405237V2

Last week 688 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 212 articles were added to DynaMed content.

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

Statin Discontinuation Might Increase Quality of Life in Patients with Advanced Life-Limiting Illness without Affecting Median Survival

Reference: JAMA Intern Med 2015 Mar 23 early online (level 2 [mid-level] evidence)

Patients with advanced life-limiting illness commonly take a number of disease-specific medications as well as medications for symptoms and comorbidities (J Am Geriatr Soc 2007 Apr;55(4):590).  Polypharmacy can be associated with increased risk of adverse events, decreased quality of life, and increased financial burden (Arch Intern Med 2006 Mar 27;166(6):605).  Discontinuing unnecessary medications may improve the patient’s overall well-being, but determining which medications may be safely discontinued can be difficult (J Am Geriatr Soc 2008 Oct;56(10):1946, Drugs Aging 2013 Sep;30(9):655).  Since the clinical benefits of statins in the primary and secondary prevention of cardiovascular disease take time to accrue and statins may be associated with an increased risk of adverse events such as gastrointestinal symptoms, myopathy, and musculoskeletal pain  (JAMA 1999 Dec 22-29;282(24):2340), statins have been identified as a reasonable candidate for discontinuation in patients with limited life expectancy.  A recent randomized trial compared statin discontinuation vs. continuation in 381 patients (mean age 74 years) with advanced life-limiting illness on statin therapy for ≥ 3 months.  All patients included in this trial had an estimated life expectancy of 1 month to 1 year and recent functional status deterioration (unrelated to cardiovascular health/status).  Most patients (69%) had been taking statins for > 5 years and nearly half of patients (48.8%) had a primary diagnosis of cancer.

Although this trial was originally designed to determine the effect of statin discontinuation on survival, this primary outcome was modified to death within 60 days after a prespecified interim analysis observed a longer median survival than initially projected.  Median duration of follow-up was 18 weeks and overall mean survival was 213 days.  Comparing statin discontinuation vs. continuation, death within 60 days occurred in 23.8% vs. 20.3% (not significant) and median time to death was 229 days vs. 190 days (not significant).  There were also no significant differences in cardiovascular-related events, physical symptoms, statin-specific symptoms, or performance status.  Statin discontinuation was associated with an increased total McGill Quality of Life score compared to statin continuation (7.11 vs. 6.85, p  = 0.04).  Discontinuation of statins was also associated with a per patient cost savings of $3.37 per day, totaling on average $716.46 for the remainder of the patient’s life.

This trial suggests that statin discontinuation may not influence survival or increase the rate of cardiovascular events in patients with advanced life-limiting illness, but may be associated with a small improvement in patient quality of life and significant monetary savings. While these results suggest the benefits of discontinuation may outweigh the risk of cardiovascular events in patients with limited life expectancy, these results do not definitively prove that statin discontinuation does not impact patient survival (likely underpowered for this outcome). The optimal timing for end of life statin discontinuation, however, requires further investigation.

For more information, see the Statins for prevention of cardiovascular disease topic in DynaMed.

Quick Access to Clinical Answers with the DynaMed App

DynaMed users can access valuable evidence-based content anywhere with the updated DynaMed mobile app. The app has been redesigned to make it easier and faster for physicians to find answers to clinical questions. The app features an improved user experience, seamless authentication, and easy access to the latest clinical content. It provides offline access and the ability to denote favorites, email topics, and write and save notes about particular topics. Users download the complete DynaMed content set and periodically receive notifications to update the content.

The DynaMed app is complimentary for all personal and institutional DynaMed subscriptions. The app has also been designed for easy one-time authentication via email, making the process as convenient as possible.

The app can be downloaded from the iTunes Store or Google Play. For more information, please visit the DynaMed Mobile Access page.

Critical Appraisal of the Medical Literature: A Simplified Approach

July 8 9, 2015 Portland State University - Portland, Oregon.

Join our Editorial Board members Sheri Strite and Michael Stuart and improve your critical appraisal skills. We aim to make critical appraisal of the medical literature meaningful, useful, simple, and doable. This program will be particularly helpful to those who routinely evaluate the medical literature.

Visit the Seminar page for more details.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: Gastroenterology, Nephrology, Oncology (especially Breast cancer and Pancreatic cancer), Ophthalmology, and Pediatric Neurology.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

DynaMed Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
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