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Choosing Wisely, the initiative for medical cost-effectiveness (don't call it rationing!) of the American Board of Internal Medicine, included the use of vasodilators for pulmonary hypertension owing to left heart disease or hypoxemic lung disease (WHO Groups II and III) as #2 on its top five "no-no's" in its new pulmonology section.
The "Five Things Physicians and Patients Should Question" in pulmonology were co-authored by the American College of Chest Physicians (ACCP) and American Thoracic Society (ATS), and were presented at the October 2013 Chest meeting in Chicago. They included this language re: vasodilators for pulmonary hypertension:
Don’t routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (Groups II or III pulmonary hypertension).
Evidence and clinical practice guidelines have not established benefits of vasoactive agents (e.g., prostanoids, phosphodiesterase inhibitors, endothelin antagonists) for patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases. Moreover, the use of these agents may cause harm in certain situations and incurs substantial cost and resource utilization. Patients should be carefully assessed (including at a minimum right heart catheterization, echocardiography, chest CT, six minute walk test and pulmonary function testing) to confirm that they have symptomatic pulmonary arterial hypertension prior to having approved agents initiated.
These drugs are approved to treat pulmonary hypertension WHO Group I patients, not those in Groups II or III. It's unclear how often vasodilators are used off-label to treat pulmonary hypertension due to these far more common conditions (e.g., left-sided congestive heart failure, COPD, and interstitial lung disease). But at thousands of dollars per month per patient for most vasodilators, even a little off-label use goes a long way at increasing health care costs, seems to be the message.
Some may take issue with the blanket recommendation against vasodilator use for pulmonary hypertension due to idiopathic pulmonary fibrosis (a study in NEJM in 2010 showed sildenafil seemed to slightly improve oxygenation, dyspnea, and quality of life).
Choosing Wisely's other four recommendations in pulmonology are:
- Don't overscan indeterminate pulmonary nodules: Don’t perform CT scans for pulmonary nodules any more frequently than recommended by the Fleischner Society or ACCP guidelines.
- Follow-up all post-hospitalization oxygen prescriptions within 90 days. For all patients discharged with a new prescription for home oxygen, re-check the patient within 3 months for ongoing need for ambulatory oxygen therapy before renewing the prescription. Many patients won't need it at that point.
- Don't use CT-angiography ("CT-PE protocols") for patients with a low clinical probability of pulmonary embolism (by Wells or Geneva scores) and a normal result on a highly sensitive D-dimer test (e.g., ELISA). CT scans to "rule out PE" have skyrocketed (usually in emergency rooms), with unlikely benefit, increasing risks for radiation-induced cancer.
- Don't screen low-risk patients for lung cancer. The benefits of low-dose chest CT for lung cancer screening were shown in patients 55-74, with 30 pack-years or more of smoking, quit less than 15 years. Even among this group, 320 people needed screening to save a life from lung cancer. Lung cancer screening may be more risky than helpful in most lower-risk people, and shouldn't be offered, argue the Choosing Wisely crew.