5 Artikel edisi Maret Minggu 2-3 2018 Dokter Mitra YesDok.

Terkait guideline baru dalam diagnosis/terapi/tambahan baru

(mohon dibaca karena akan ada E-quiz pada akhir bulan)

1. Cognitive Impairment

American Academy of Neurology

Clinicians should assess for mild cognitive impairment (MCI) with validated tools in
appropriate scenarios.
When performing a Medicare Annual Wellness Visit, clinicians should not rely on historical
report of subjective memory concerns alone when assessing for cognitive impairment.

In the presence of cognitive impairment, clinicians need to distinguish between a diagnosis of

MCI and one of dementia, although the boundary is not always clear. Diagnosing dementia
prematurely can lead to negative consequences for patients and families.
Clinicians should evaluate patients with MCI for modifiable risk factors, assess for functional
impairment, and assess for and treat behavioral/neuropsychiatric symptoms.

Cognitively impairing medications should be discontinued where possible and behavioral

symptoms treated.
Clinicians may choose not to offer cholinesterase inhibitors; if offering, they must first discuss
lack of evidence.

Clinicians should recommend regular exercise. In patients with MCI, treatment with exercise
training for 6 months is likely to improve cognitive measures.
Clinicians may recommend cognitive training.
Clinicians should discuss diagnosis, prognosis, long-term planning, and the lack of effective
medicine options, and may discuss biomarker research with patients with MCI and families.

References
 Brooks M. New AAN Guideline: Exercise Has Cognitive Benefits in MCI. Medscape
News. WebMD Inc. December 28,
2017. https://www.medscape.com/viewarticle/890679
 Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: Mild
cognitive impairment: Report of the Guideline Development, Dissemination, and
Implementation Subcommittee of the American Academy of
Neurology. Neurology. 2018 Jan 16;90(3):126-
35. http://n.neurology.org/content/early/2017/12/27/WNL.0000000000004826
2. Cancer and Sexual Problems

American Society of Clinical Oncology

It is recommended that there be a discussion with the patient, initiated by a member of the
health care team, regarding sexual health and dysfunction resulting from cancer or its treatment.
Psychosocial and/or psychosexual counseling should be offered to all patients with cancer,
aiming to improve sexual response, body image, intimacy and relationship issues, and overall
sexual functioning and satisfaction.

Medical and treatable contributing factors should be identified and addressed first.

In women with symptoms of vaginal and/or vulvar atrophy, lubricants in addition to vaginal
moisturizers may be tried as a first option. Low-dose vaginal estrogen, lidocaine, and
dehydroepiandrosterone may also be considered in some cases.

In men, medication such as phosphodiesterase type 5 inhibitors may be beneficial, and surgery
remains an option for those with symptoms or treatment complications refractory to medical
management.

Both women and men experiencing vasomotor symptoms should be offered interventions for
symptomatic improvement, including behavioral options such as cognitive-behavioral therapy,
slow breathing and hypnosis, and medications such as venlafaxine and gabapentin.

References
 Larkin M. ASCO Guideline Addresses Sexual Issues in Cancer Patients. Reuters
News. December 21, 2017. https://www.medscape.com/viewarticle/890423
 Carter J, Lacchettti C, Andersen BL, et al. Interventions to Address Sexual Problems in
People With Cancer: American Society of Clinical Oncology Clinical Practice
Guideline Adaptation of Cancer Care Ontario Guideline. J Clin Oncol. 2017 Dec
11. http://ascopubs.org/doi/full/10.1200/JCO.2017.75.8995
3. Nausea and Vomiting in Pregnancy

American College of Obstetricians and Gynecologists

Use vitamin B6 (pyridoxine) alone or in combination with doxylamine as first-line
pharmacotherapy, as they are safe and effective.
Clinicians should encourage women to take prenatal vitamins for 1 month before fertilization,
as it may decrease the incidence and severity of nausea and vomiting during pregnancy.

Supportive therapy is recommended for abnormal maternal thyroid tests caused by gestational
transient thyrotoxicosis or hyperemesis gravidarum, or both, but ACOG recommends against
antithyroid medications.

Ginger may be used as a nonpharmacologic option, as it has had some beneficial effects in the
treatment of nausea and vomiting of pregnancy.
Methylprednisolone has been effective in some refractory cases of severe nausea and vomiting
of pregnancy; however, it should be considered a last-resort treatment as a result of its risk
profile.

Early treatment of nausea and vomiting of pregnancy may help prevent it from progressing to
hyperemesis gravidarum.
Intravenous hydration should be administered to patients who are unable to tolerate oral fluids
for a prolonged period and if clinical signs of dehydration develop.

Strongly consider correction of ketosis and vitamin deficiency. Include dextrose and vitamins
in therapy in cases of prolonged vomiting; consider administering thiamine before dextrose
infusion to prevent Wernicke encephalopathy.

Begin enteral tube feeding (nasogastric or nasoduodenal) as first-line treatment to support

nutrition for women with hyperemesis gravidarum who do not respond to medical therapy and
who are unable to maintain their weight.

Use peripherally inserted central catheters only as a last resort in women with hyperemesis
gravidarum, as significant complications are associated with this intervention, and there is the
potential for severe maternal morbidity.

References
 Brown T. New Guidelines on Nausea, Vomiting in Pregnancy. Medscape
News. WebMD Inc. December 22,
2017. https://www.medscape.com/viewarticle/890504
 ACOG Practice Bulletin No. 189: Nausea And Vomiting Of Pregnancy. Committee on
Practice Bulletins-Obstetrics. Obstet Gynecol. 2018 Jan;131(1):e15-
e30. https://journals.lww.com/greenjournal/Abstract/2018/01000/
ACOG_Practice_Bulletin_No__189___Nausea_And.39.aspx
4. Testosterone Deficiency

British Society for Sexual Medicine

Screen all men presenting with ED, loss of spontaneous erections, or low sexual desire.
Screen for TD in all men with type 2 diabetes mellitus, BMI >30 kg/m2, or waist circumference
>102 cm.

Screen for TD in all men on long-term opiate, antipsychotic, or anticonvulsant medication.

Restrict diagnosis of TD to men with persistent symptoms suggesting TD and confirmed low
T.

Measure fasting T levels in the morning before 11 AM, acknowledging that, in normal life,
nonfasting levels could be up to 30% lower.
Repeat total testosterone (TT) assessment on ≥2 occasions by a reliable method; in addition,
measure free testosterone (FT) in men with levels close to the lower normal range (8-12
nmol/L) or those with suspected or known abnormal sex hormone binding globulin (SHBG)
levels.

Measure luteinizing hormone (LH) serum levels to differentiate primary from secondary TD.
Perform cardiovascular, prostate, breast, and hematologic assessments before start of
treatment.

Offer T therapy to symptomatic men with TD syndrome for treated localized low-risk prostate
cancer (Gleason score <8, stages 1-2, preoperative PSA level <10 ng/mL, and not starting
before 1 year of follow-up) and without evidence of active disease (based on measurable PSA
level, DRE result, and evidence of metastatic disease).

Assess response to therapy at 3, 6, and 12 months and every 12 months thereafter.

Aim for a target TT level of 15-30 nmol/L to achieve optimal response.
Assess prostate health by PSA and DRE before commencing testosterone replacement therapy
followed by PSA at 3-6 months, 12 months, and every 12 months thereafter.

Reference
 Hackett G, Kirby M, Edwards D, et al. British Society for Sexual Medicine Guidelines
on Adult Testosterone Deficiency, With Statements for UK Practice. J Sex Med. 2017
Dec;14(12):1504-23. http://www.jsm.jsexmed.org/article/S1743-6095(17)31538-
2/fulltext
5. Urinary Incontinence

European Association of Urology

Abdominal examination is recommended to exclude urinary retention and pelvic masses.
Perineal examination recommended, including external genitalia, vaginal or rectal
examination, pelvic floor contraction, and examination of the dermatomes innervated by sacral
roots.

Assess estrogen status in women.

Perform urinalysis as a part of the initial assessment of a patient with UI.
Do not routinely treat asymptomatic bacteriuria in elderly patients to improve UI.
When measuring postvoid residual urine volume (PVR), use ultrasound.
Measure PVR when assessing patients with complicated UI.

PVR should be measured in patients receiving treatments that may cause or worsen voiding
dysfunction.
Do not routinely carry out urodynamics when offering treatment for uncomplicated SUI.
Perform urodynamics if the findings may change the choice of invasive treatment.

Do not use urethral pressure profilometry or leak point pressure to grade severity of
incontinence.
Use a pad test when quantification of UI is required.
Do not routinely carry out imaging of the upper or lower urinary tract as part of the assessment
of UI.

Offer antimuscarinic drugs or mirabegron for adults with urge UI (UUI) who failed
conservative treatment.

Consider extended release formulations of antimuscarinic drugs whenever possible.

If an antimuscarinic treatment proves ineffective, consider dose escalation or offering an
alternative antimuscarinic formulation or mirabegron or a combination.

Long-term antimuscarinic treatment should be used with caution in elderly patients, especially
those who are at risk of, or have, cognitive dysfunction.

Offer duloxetine in selected patients with symptoms of stress UI (SUI) when surgery is not
indicated. Duloxetine should be initiated and withdrawn using dose titration because of high
risk of adverse event.

Reference
 Nambian AK, Bosch, R, Cruz F, et al. EAU Guidelines on Assessment and Nonsurgical
Management of Urinary Incontinence. Eur Urol.2018 Feb
2. http://www.europeanurology.com/article/S0302-2838(18)30002-2/fulltext