2010 ENDO Daily Day 4 - (Page 8)
June 19-22, 2010
Draft CAH guideline revealed Monday
he Endocrine Society and af?liated organizations released a new draft clinical practice guideline for the treatment of congenital
“There is insuf?cient data to recommend prenatal treatment,” Dr. Speiser said. “This is not standard of care.” The task force also recommended against the routine use of experimental therapies to delay puberty and increase adult height in children affected by CAH. The guidelines also suggest that adrenalectomy be avoided and encourage early, single-stage surgical repair for severely virilized girls. The recommendations represent the consensus view of the panel. The guidelines were reviewed and approved by The En-
human literature suggests that prenatal dexamethasone carries a 1.7 odds ratio for orofacial clefts and decreases birth weight by about 0.5 kg. A second problem is deciding whom to treat. External genital differentiation begins at about seven weeks gestation, while a conclusive CAH diagnosis cannot be made until about 12 weeks. “Effective treatment must precede diagnosis,” Dr. Speiser said. “If you wait for diagnosis, virilization has already begun.” The task force was hampered by the lack of high-quality data. Of 1,083 studies originally identi?ed, only four met the quality criteria agreed upon by the sponsoring groups. The pooled data suggest that prenatal treatment can decrease the Prader score for genital ambiguity by about 2.33 points, a modest improvement, according to Dr. Speiser. Side effects included stillbirth (odds ratio 1.27), malformation (odds ratio 1.51), maternal edema (odds ratio 1.83) and maternal striae (odds ratio 1.62). Outcome data on prenatal treatment are suspect. Most are derived from questionnaires, not from physical examination of the offspring. And because dexamethasone prenatal treatment is relatively new, no offspring have yet reached middle age where many problems can be expected to present. If prenatal treatment is to be used, the task force recommended the dose should be below 17 mg/m2/day or lower. Data show a sharp increase in side effects at a dose of 18 mg/m2/day and higher. ?
Practice Management Sessions
In response to the popularity of the Practice Management Sessions at ENDO ’09, the series has returned for 2010 with improvements to accommodate more attendees. Once again, the Practice Management Sessions will offer insights for practicing physicians on how to manage the business side of private and academic clinics. The sessions, which will explore a range of timely topics of interest, including the patient-centered medical home and Medicare audits, will take place during the regular educational program:
adrenal hyperplasia due to steroid 21-hydroxylase de?ciency to an over?ow audience on Monday morning. The draft was prepared by a task force of 11 clinicians based on a systematic review and evaluation of the available evidence.
Avoiding surgery is the primary rationale for considering prenatal treatment. Surgical techniques and success rates have improved greatly in recent years while the risks of prenatal treatment have not.
– Phyllis Speiser, MD “The goal is to prevent ambiguity in CAH females,” said task force chair Phyllis Speiser, MD, Schneider Children’s Hospital and New York University School of Medicine, New York. “The risks include long term and short term safety concerns for infants and mothers and the recognition that seven out of eight fetuses treated derive no bene?t.” The task force recommended universal newborn screening for severe steroid 21-hydroxylase de?ciency followed by con?rmatory tests. The panel also recommended that prenatal treatment of CAH continue to be regarded as an experimental procedure. Prenatal treatment should not be conducted on a routine basis but should be con?ned to formal clinical study situations under institutional review board protocol.
docrine Society’s Clinical Guidelines Subcommittee and Clinical Affairs Core Committee, Society members and The Endocrine Society Council. The task force incorporated changes in response to written comments at each stage. “Avoiding surgery is the primary rationale for considering prenatal treatment,” Dr. Speiser said. “Surgical techniques and success rates have improved greatly in recent years while the risks of prenatal treatment have not.” The typical prenatal treatment is dexamethasone, which crosses the placental barrier and may affect the fetal hypothalamic-pituitary-adrenal axis. Prenatal use of the drug is associated low birth weight, central nervous system effects, cleft palate, liver enlargement, a decrease in fetal beta cells and other negative outcomes in animals. The
TUESDAY, JUNE 22
12:15 – 1:00 P.M.
Coding & Billing in Diabetes Care
Susan Thurston, Medicare Auditor, Colorado
TUESDAY, JUNE 22
Childhood Obesity: Causes, Consequences and Prevention
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