News Release 

Aggressive and agitated behaviors in dementia are better treated without medications

American College of Physicians

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.

1. Aggressive and agitated behaviors in dementia are better treated without medications

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0993

URLs go live when the embargo lifts

Nonpharmacologic treatments, such as massage and touch therapy, seemed to be more effective than pharmacologic treatments for reducing aggression and agitation in adults with dementia. Findings from a systematic review and meta-analysis are published in Annals of Internal Medicine.

Both pharmacologic treatments, such as antipsychotics and antidepressants, and nonpharmacologic treatments, such as exercise and massage therapy, are used to treat neuropsychiatric symptoms in persons with dementia. Despite the risk for potential harms, drug prescribing remains high.

Researchers from the Li Ka Shing Knowledge Institute, St. Michael's Hospital-Unity Health Toronto reviewed 163 published randomized controlled trials comparing interventions for treating aggression and agitation in adults with dementia to compare the efficacy of pharmacologic and nonpharmacologic treatments. Across five outcomes, multidisciplinary care, massage and touch therapy, music therapy, music combined with massage and tough therapy, and cognitive stimulation were clinically effective compared with usual care. Although certain pharmacologic treatments (dextromethorphan-quinidine and cannabinoids) were effective compared to placebo or usual care in subgroup analyses, the authors note that effective nonpharmacologic treatments should be prioritized given the known harms associated with certain pharmacologic treatments.

According to the authors, these findings suggest that greater emphasis should be placed on nonpharmacologic approaches for treating aggression and agitation in persons with dementia.

Notes and media contacts: For an embargoed PDF please contact Angela Collom at acollom@acponline.org. To speak with the lead author, Jennifer Watt, MD, please contact Michael Oliveira at Michael.Oliveira@unityhealth.to.

2. Rivaroxaban nearly doubled the risk for recurrent thrombosis in APS compared with warfarin

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0291

Editorial: http://annals.org/aim/article/doi/10.7326/M19-2815

Summary (free): http://annals.org/aim/article/doi/10.7326/P19-0013

URLs go live when the embargo lifts

Rivaroxaban did not show noninferiority to dose-adjusted warfarin in patients with antiphospholipid antibody syndrome (APS), an autoimmune disorder that causes an increased risk for blood clots. In fact, rivaroxaban showed a non-statistically significant near doubling of the risk for recurrent thrombosis in study participants. Findings from a randomized noninferiority trial are published in Annals of Internal Medicine.

Long-term anticoagulation with vitamin K antagonists, or warfarin, is the mainstay of therapy for thrombotic APS, but its use may be problematic because of food and drug interactions, bleeding complications, and the need for frequent monitoring. Newly available anticoagulation therapies may overcome some of these drawbacks, so comparing them is necessary.

Researchers from Vall d'Hebron University Hospital Research Institute, Barcelona, Spain, randomly assigned 190 adults with thrombotic APS to receive either rivaroxaban or dose-adjusted warfarin for 3 years to determine whether rivaroxaban was noninferior to warfarin. They found that a higher proportion of patients in the rivaroxaban group had new blood clots. The proportion of patients with major bleeding events was similar in both groups. More stroke events occurred in the rivaroxaban than the warfarin group.

According to the researchers, these findings suggest that rivaroxaban should not be used to prevent blood clots in patients with APS.

Notes and media contacts: For an embargoed PDF please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Josefina Cortés-Hernández, MD, PhD, please contact her directly at fina.cortes@vhir.org.

3. Nifedipine could cause adverse events when used to prevent labor in women with aortic stenosis

Abstract: http://annals.org/aim/article/doi/10.7326/L19-0481

URLs go live when the embargo lifts

Physicians should consider using a drug other than nifedipine to prevent labor in women with aortic stenosis, as the drug may cause adverse events in this population. Findings from a brief case report are published in Annals of Internal Medicine.

Nifedipine, an antihypertension medication, is the preferred agent for premature labor, given its effectiveness in suppressing uterine contractions. While the drug works well for healthy women, it may lead to issues for women with cardiovascular dysfunction.

Physicians from Brown University report the case of a 31-year-old woman with moderately severe aortic stenosis who received pre-term labor prophylaxis with nifedipine after an uncomplicated planned intrauterine procedure and subsequently went into shock. Physicians taking over care gave the patient medications to control her blood pressure and reverse the effects of nifedipine, leading to continued improvement in blood pressure over the next 8 hours.

According to the authors, nifedipine's class and potency make it potentially harmful to pregnant women with cardiovascular issues. They encourage clinicians to consider ordering echocardiography for any pregnant woman with suspected aortic stenosis. When aortic stenosis is present, clinicians should consider using a drug other than nifedipine for tocolysis.

Notes and media contacts: For an embargoed PDF please contact Angela Collom at acollom@acponline.org. To speak with lead author Cullen Soares, MD, please him directly at cullen@chestersoares.com.

Also new in this issue:

Cases in Precision Medicine: A Personalized Approach to Stroke and Cardiovascular Risk Assessment in Women

Natalie A. Bello, MD, MPH; Eliza C. Miller, MD; Kirsten Lawrence Cleary, MD, MSc; and Ronald Wapner, MD

Precision Medicine

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1601

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