What You Should Know About NSAIDs
The potential side effects of nonsteroidal antiinflammatory drugs (NSAIDs), including COX-2 inhibitors, have been well documented recently. The highly publicized Public Health Advisory from the Food and Drug Administration on celecoxib (Celebrex) and rofecoxib (Vioxx) has increased the discussion about the safety of such agents. What types of side effects should one be wary of with NSAIDs and COX-2 inhibitors, and what screening precautions can one take? Nicholas Grumbine, DPM, has seen gastrointestinal (GI) difficulties and bleeding in patients taking NSAIDs, particularly if they are taking other medications as well. Dr. Grumbine, a Diplomate of the American Board of Podiatric Surgery, treats many cases of reflex sympathetic dystrophy and says 25 to 40 percent of those patients have had adverse GI side effects on NSAIDs. Overall, Dr. Grumbine has also seen intestinal bleeding in less than 5 percent of patients who take NSAIDs and other medications. A recent study in Clinical Gastroenterology and Hepatology echoes the concerns about GI side effects. Researchers tested 41 patients with various arthridities, 21 percent of whom were taking NSAIDs every day for more than three months. Seventy-one percent of NSAID users experienced small bowel injury compared to 10 percent of the control subjects, according to the study. The study authors noted that 10 NSAID users had mild injuries while five NSAID users experienced erosions or large ulcers. Study authors note that endoscopically evident small-intestinal mucosal injury is “very common” in chronic users of NSAIDs. They also note that none of the patients experienced any problems with the diagnostic capsule endoscopy procedure. Erwin Juda, DPM, says one may use endoscopes to screen for potential GI problems but says this is not feasible for every patient. To screen for patients who may experience GI side effects on NSAIDs, Drs. Grumbine and Juda emphasize the importance of a thorough patient history. Dr. Grumbine says one should ascertain if the patient has had any bleeding problems, dark stool, abdominal cramps and anemia. Dr. Juda says one should document if patients have any history of ulcers and GI problems, and ask them if they are already taking NSAIDs. Taking multiple NSAIDs may be particularly problematic, according to Dr. Grumbine. He recalls a moderately obese patient who had severe degenerative joint disease and had undergone a triple arthrodesis. Dr. Grumbine says he had problems controlling the patient’s post-op bleeding after prescribing aspirin. Unfortunately, the woman did not tell him that she was already taking Motrin and a stronger Mexican aspirin. Her hemoglobin dropped from 14 to 8 in two days and Dr. Grumbine says he had to transfuse three units of blood. “People sometimes take herbs and don’t tell you, and adverse effects can accumulate with the NSAIDs or COX-2 inhibitors,” points out Dr. Grumbine. As this issue went to press, the FDA’s Arthritis Advisory Committee and the Drug Safety and Risk Management Advisory Committee were scheduled to have a public meeting to discuss concerns over NSAIDs.
When Mental Illness Affects Care For Diabetes Patients
By Brian McCurdy, Associate Editor Ensuring the compliance of patients with diabetes is often challenging. When diabetes is coupled with a mental disorder, one must take special precautions to avoid complications and facilitate the best possible clinical outcome. A new study conveys problems with compliance in diabetic and mentally ill patients. The study, recently published in Medical Care, analyzed administrative claims data of Blue Cross/Blue Shield of Iowa from 1996 to 2001. Authors found that of 26,020 patients with diabetes, 25 percent (6,627) had a coexisting mental disorder. In addition to compliance problems, study authors note diabetic patients with mental disorders were more likely to have diabetic complications. Researchers speculate this may be due to mentally ill patients’ poor reception of HbA1c testing. The study advises DPMs to educate people with mental disorders more aggressively about controlling their blood sugar. Compliance is the biggest issue for patients with diabetes and mental illness, according to John McCord, DPM. For example, patients may have diabetic neuropathy that can contribute to foot ulcers and other problems but these may not be a high priority for those that have mental illness as well. In these cases, Dr. McCord says enlisting the help of the patient’s family or friends may help facilitate compliance for treating the lower-extremity problems. Dr. McCord, a Diplomate of the American Board of Podiatric Surgery, also tries to cultivate the patient’s trust to ensure compliance.
Blending Practical Concerns With Compassion
Dr. McCord says care can be particularly challenging if the patient has a drug problem as well. Dr. McCord says one must weigh issues such as mental problems and drug abuse when considering treatment for a lower-extremity complication related to diabetes. Besides coping with medical issues in diabetic patients, there are practical angles to consider, such as the medical/legal issues that can arise in treating patients with mental disorders. Dr. McCord advises DPMs to document their care plans and the patient’s progress or lack thereof in following the plan. “It is best to simply state the facts and not to assign blame to the patient every time things go wrong,” says Dr. McCord. Dr. McCord says it is particularly important to temper medical care and practical considerations with compassion, especially in those with mental illness. For example, when a patient loses a leg, the compassion a DPM shows in the office may be all that the patient remembers. Dr. McCord notes that he recently treated an elderly patient who had diabetes, mental illness and a problem with alcohol. The patient eventually had to have his leg amputated after losing a battle with gangrene. “I felt very bad when I told him that I had done all I could,” recalls Dr. McCord. “He patted me on the back and said, ‘That is OK, doc. Hell, you tried as hard as you could.’”
Ohio College Emphasizes Integrated Clinical Education
By Brian McCurdy, Associate Editor For podiatric medical students, entering the “real world” of hospital rotations can be a transition. At the Ohio College of Podiatric Medicine, a patient rotation program eases that transition by giving students a taste of caring for patients before graduation. Simulated patient rotation prepares students for interacting with patients before the future DPMs enter a clinical setting. The rotations make students “more comfortable and competent” when they begin seeing patients, according to Scott A. Spencer, DPM, Associate Professor of Orthopedics/Biomechanics. In addition, he notes the Ohio school offers a sterling physical diagnosis program, which incorporates “cutting edge” computer simulations of patient visits. Dr. Spencer says the school’s open clinic setting ensures the school’s various departments work together to provide students with a complete education in podiatric care. The rapport between students and faculty “sets the stage for the integrated clinical education process,” says Dr. Spencer. He says the Ohio school’s faculty’s dedication and hands-on approach enhances students’ experiences. “This translates into a more comfortable interaction which I think makes it easier for students to acquire the information they need to be the best podiatric practitioners possible,” says Dr. Spencer.
In Brief
March 21 is the deadline for DPMs to opt out of the class action settlement against CIGNA Healthcare, according to the American Podiatric Medical Association (APMA). DPMs, who treated CIGNA patients between 1990 and 2004, have until May 27 to submit a claim form to receive a cash settlement. The APMA also notes that DPMs can designate their share of the settlement to the association, which will use the funding for scholarships.
Clarification
In the January issue of Podiatry Today, the article, “Inside Secrets To DME Billing,” listed codes for diabetic shoes dispensed from podiatry offices. The codes should have read as follows: Custom depth shoe: A5501 Non-custom depth shoe: A5500 Prefab insole (not heat molded): A5510 Prefab insole (heat molded): A5509/K0628 Custom molded insole: K0629 Longitudinal insoles with arch and filler for amputated portion foot: L5000 Participation in Medicare Part B and DMERC is linked so participation status is binding for all Medicare business. List the National Supplier Clearinghouse as a certificate holder for the policy that covers the place of business, employees and customers. This could be one’s malpractice carrier if it covers such liability or another professional insurance carrier. Check with both carriers for their coverage liability. The malpractice carrier alone is not appropriate.
