Updates: Lung cancer screening, gonorrhea intervening, and primary aldosteronism gleaning!

Lung cancer screening: updated USPSTF guidelines!

Cam previously taught us about lung cancer screening (LCS), pointing out that there are multiple organizations each with slightly different guidelines and that, ultimately, shared decision-making is crucial to decide who and when to screen. 

The USPSTF recently updated its recommendations for LCS in 2 ways: 

  • expanding the age range from 55-80yo to 50-80yo, and 
  • decreasing the number of pack years from ≥30 to ≥20. 

With this update, the population eligible for LCS will increase from approximately 14% to 22%. While that sounds promising, there’s a lot of controversy with LCS. Only 5-10% of patients eligible under the prior recommendation have been screened, with substantial racial and socioeconomic disparities. And, incredibly, some Medicaid and private insurance plans still don’t cover LCS.

Gonorrhea: updated CDC recommendations!

Kenzie previously taught us a ton about STI screening, diagnosis, and treatment. Last December, CDC updated their guidelines for the treatment and management of gonorrhea: 

  • Treat gonorrhea infections with a single 500 mg injection of ceftriaxone.
  • Test-of-cure is not needed for people with uncomplicated urogenital/rectal gonorrhea unless symptoms persist.
  • Test-of-cure is recommended in people with pharyngeal gonorrhea 7-14 days after initial treatment. 
  • Patients treated for gonorrhea should be retested 3 months after treatment to ensure there is no reinfection.
  • As always, facilitate partner testing and treatment.

The main differences in the first point are that the dose of CTX is higher and that we no longer need to do combination therapy with azithromycin for treatment of gonorrhea. The latter results from increasing antibiotic resistance. Specifically, the percentage of N. gonorrhoeae isolates with reduced susceptibility (MIC ≥2.0 μg/mL) to azithromycin increased more than sevenfold over 5 years (from 0.6% in 2013 to 4.6% in 2018). 

Primary Aldosteronism: more studies, more questions!

We previously looked at a study suggesting that primary aldosteronism (PA) is underdiagnosed and can affect patients of any BP category. 

A recent VA study in the Annals showed that only 1.6% of patients (n = 216k) with resistant HTN were tested for PA, which is not encouraging considering that the prevalence of PA is estimated around 8-20% (and maybe even higher.) 

Screening for PA with an aldosterone-renin ratio can be a pain because we have to stop most anti-hypertensive meds (except BB) for 2-4 weeks prior to testing, at least according to most guidelines. This step is necessary because anti-hypertensive drugs tend to raise renin and aldosterone, but not proportionately, leading to unreliable results and a lot of false negatives. Nevertheless some resources suggest we should initially screen for PA without stopping the meds, noting that screening results can still be interpreted accurately as long as renin is suppressed.

But all this leads to a simple question: Why don’t we screen for PA when we first diagnose a patient with HTN? The most recent ACC/AHA guidelines say to check several studies when we first diagnose HTN: CBC, BMP, TSH, UA, and ECG. Consider the utility of TSH—thyroid disease causes <1% of secondary HTN while PA causes at least 8%, so why are we screening for thyroid disease but not PA? One reason may be that nobody knows if it would be cost effective to screen for PA. For instance, if a patient screens positive for PA then the next step would be to get an adrenal CT ($$), which would potentially be followed by adrenal venous sampling ($$$) and surgery ($$$$). Of course, people who don’t want surgery could be treated with a mineralocorticoid receptor antagonist like spironolactone.

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