Tools for Practice

Tools for Practice articles have been produced by the PEER team in collaboration with the ACFP since 2009.
Click here for the entire collection

Recent Tools for Practice

Tools for Practice #256 – Hydroxychloroquine with or without azithromycin for COVID-19

Is hydroxychloroquine (with or without azithromycin) effective in treating COVID-19?

Bottom Line: One nonrandomized study found that more hydroxychloroquine/azithromycin patients tested negative for virus at days 3 and 6 but clinical outcomes were not reported. One unblinded randomized trial showed no effect from hydroxychloroquine on viral or clinical outcomes. Without further evidence, hydroxychloroquine is not appropriate for patients with COVID-19 in primary care.  Read More

Tools for Practice #255 – Exercise for osteoarthritis pain: how strong is the evidence?

Is exercise effective for pain management in hip/knee osteoarthritis?

Bottom Line: In adults with knee or hip osteoarthritis, exercise can lead to ~30% pain improvement for 47% of patients versus 21% with no exercise at 6-104 weeks, benefiting one additional person for every 4 treated. The type of exercise does not significantly affect the results, however most included trials utilized physiotherapy. Read More

Tools for Practice #254 – Should family physicians add “physical activity” to their prescription pads?

Do simple physical activity prescriptions increase physical activity levels?

Bottom Line: Physical activity prescriptions, combined with patientspecific goals and monitoring, may increase physical activity levels by up to ~1200 steps/day at ~1 year, with an additional 1 person becoming active for every 10 prescribed activity compared to general advice alone. Read More

Tools for Practice #253 – Pharmacologic management of alcohol use disorder: worth a shot?

Which Health Canada approved pharmacologic treatments are effective for alcohol use disorder?

Bottom Line: Both acamprosate and naltrexone demonstrate benefit for abstinence from alcohol when compared to placebo. For every 12 patients treated with acamprosate, and every 20 patients treated with naltrexone, one fewer patient will return to drinking compared to placebo after 12-52 weeks. If harm reduction is the goal, naltrexone can reduce return to heavy drinking for one out of every 13 patients. Read More

Tools for Practice #252 – Electronic Cigarettes – Hoot that helps, hurts, or just hype?

Do electronic cigarettes help smokers quit smoking?

Bottom Line: Compared to nicotine replacement therapy (NRT) or placebo electronic cigarettes, two randomized controlled trials (RCTs) demonstrate that nicotine electronic cigarettes (NEC) aid in smoking cessation [number needed to treat (NNT)=13, 15]. Two other RCTs found no difference in cessation rates. Serious lung disease and deaths have been reported with electronic cigarettes (e-cigarette) use. Tetrahydrocannabinol (THC) and vitamin E acetate containing e-cigarettes should be avoided. Read More

PEER Picks

#255 – Exercise for osteoarthritis pain: how strong is the evidence?

Is exercise effective for pain management in hip/knee osteoarthritis?

Read More

#250 – DPP-4 inhibitor update: Thousands studied but still no evidence of clinical benefits

In type 2 diabetes, do dipeptidyl peptidase-4 (DPP-4) inhibitors improve patient-oriented outcomes like cardiovascular disease (CVD)?

Read More

#238 – In COPD puffers, does three-of-kind beat a pair?

In Chronic Obstructive Pulmonary Disease (COPD) patients on Long-Acting Muscarinic Antagonist (LAMA) and Long-Acting Beta-Agonist (LABA) dual therapy, does adding inhaled corticosteroids (ICS) improve outcomes?

Read More

Tools for Practice by Catagory

Anesthesiology

(3)

#244 – Injecting Evidence into Platelet-Rich Plasma Injections

Bottom Line: The best quality evidence shows no difference in pain, function, or return to sport between platelet-rich plasma, dry needling, or saline for patients with Achilles tendinopathy, lateral epicondylitis, or rotator cuff tendinopathy.

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#243 – Spread the Word: Widespread Distribution of Naloxone to Decrease Opioid-Related Deaths

Bottom Line: Offering naloxone kits and overdose related education for people who use opioids and their community may decrease opioid related deaths by ~7 per 100,000 population over one year. Effectiveness is likely influenced by magnitude of opioid problem in a given community and other confounders (like co-ingestions, co-morbidities, type and dose of opioid used).

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

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Cardiology

(4)

#248 – Hydrochlorothiazide and Squamous Cell Skin Cancer: Remember when hypertension was easy?

Bottom Line: Observational data suggest an association between hydrochlorothiazide and the risk of SCC. Causation has not been proven. Risk appears to consistently increase with dose and duration (example: 5 years of use increases risk 3-4 times). Baseline incidence of SCC is <0.1% annually. The same risk has not been established with thiazide-like diuretics (like indapamide or chlorthalidone). The benefit of switching from hydrochlorothiazide to another agent should be weighed against the risk of changing medications.

Read Tool

#247 – Fact or Fad: Intermittent fasting for sustained weight loss

Bottom Line: Although inconsistently defined, intermittent fasting (example 500 kcal/day for 2 days/week) and continuous dieting (~25% reduction in caloric intake daily) result in similar weight loss, usually ~5-9kg at 6 months-1 year. Discontinuation rates with both diets is up to ~60%.

Read Tool

#245 – Taking a hard look at the evidence: Phosphodiesterase-5-inhibitors in erectile dysfunction

Bottom Line: PDE5 inhibitors increase the proportion of successful sexual intercourse attempts to ~65% versus ~30% for placebo. For every 3 men given a PDE5 inhibitor compared to placebo, an additional 1 will have “improved erections”.

Read Tool

#239 – Need milk? Domperidone for increasing breast milk supply

Bottom Line: In mothers of pre-term infants, domperidone increases milk volume by ~90 ml more than placebo after 14 days, with an additional 1 in 5 women experiencing a 50% increase in milk supply. Doses above 30 mg/day are likely not needed and may increase the risk of arrhythmias. Optimal length of treatment unknown.

Read Tool
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Chronic Pain

(3)

#244 – Injecting Evidence into Platelet-Rich Plasma Injections

Bottom Line: The best quality evidence shows no difference in pain, function, or return to sport between platelet-rich plasma, dry needling, or saline for patients with Achilles tendinopathy, lateral epicondylitis, or rotator cuff tendinopathy.

Read Tool

#243 – Spread the Word: Widespread Distribution of Naloxone to Decrease Opioid-Related Deaths

Bottom Line: Offering naloxone kits and overdose related education for people who use opioids and their community may decrease opioid related deaths by ~7 per 100,000 population over one year. Effectiveness is likely influenced by magnitude of opioid problem in a given community and other confounders (like co-ingestions, co-morbidities, type and dose of opioid used).

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
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Dermatology

(3)

#248 – Hydrochlorothiazide and Squamous Cell Skin Cancer: Remember when hypertension was easy?

Bottom Line: Observational data suggest an association between hydrochlorothiazide and the risk of SCC. Causation has not been proven. Risk appears to consistently increase with dose and duration (example: 5 years of use increases risk 3-4 times). Baseline incidence of SCC is <0.1% annually. The same risk has not been established with thiazide-like diuretics (like indapamide or chlorthalidone). The benefit of switching from hydrochlorothiazide to another agent should be weighed against the risk of changing medications.

Read Tool

#242 – Putting the FUN in Fungi: Toenail onychomycosis treatments

Bottom Line: Up to 45-60% of patients on oral treatments (terbinafine best), 6-23% on topicals (efinaconazole best), and <10% on placebo will be “cured” after ~1 year. Topicals should be reserved for cases with minimal (≤20-40%) nail involvement.

Read Tool

#241 – “Who’s the fairest of them all?”: Topical treatments for rosacea

Bottom Line: For moderate-severe papulopustular rosacea, topical metronidazole, azelaic acid, and ivermectin have similar benefit with ~65-75% achieving patient reported improvement

Read Tool
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Emergency

(3)

#246 – Just wait a minute: Point-of-care testing for Group A Streptococcal pharyngitis

Bottom Line: Point-of-care testing, including rapid antigen detection tests and newer nucleic acid detection tests for GABHS pharyngitis are useful for ruling in a diagnosis of GABHS when positive (specificity 95%-99%). Nucleic acid detection tests may be more sensitive than rapid antigen detection tests (92% versus 85%). While immediate testing and treatment may not always be required, populations at increased risk of GABHS complications, such as Canada’s Indigenous populations, are more likely to benefit.

Read Tool

#243 – Spread the Word: Widespread Distribution of Naloxone to Decrease Opioid-Related Deaths

Bottom Line: Offering naloxone kits and overdose related education for people who use opioids and their community may decrease opioid related deaths by ~7 per 100,000 population over one year. Effectiveness is likely influenced by magnitude of opioid problem in a given community and other confounders (like co-ingestions, co-morbidities, type and dose of opioid used).

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
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Endocrinology

(3)

#247 – Fact or Fad: Intermittent fasting for sustained weight loss

Bottom Line: Although inconsistently defined, intermittent fasting (example 500 kcal/day for 2 days/week) and continuous dieting (~25% reduction in caloric intake daily) result in similar weight loss, usually ~5-9kg at 6 months-1 year. Discontinuation rates with both diets is up to ~60%.

Read Tool

#245 – Taking a hard look at the evidence: Phosphodiesterase-5-inhibitors in erectile dysfunction

Bottom Line: PDE5 inhibitors increase the proportion of successful sexual intercourse attempts to ~65% versus ~30% for placebo. For every 3 men given a PDE5 inhibitor compared to placebo, an additional 1 will have “improved erections”.

Read Tool

#239 – Need milk? Domperidone for increasing breast milk supply

Bottom Line: In mothers of pre-term infants, domperidone increases milk volume by ~90 ml more than placebo after 14 days, with an additional 1 in 5 women experiencing a 50% increase in milk supply. Doses above 30 mg/day are likely not needed and may increase the risk of arrhythmias. Optimal length of treatment unknown.

Read Tool
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  • 1
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  • 1

Gastroenterology

(2)

#247 – Fact or Fad: Intermittent fasting for sustained weight loss

Bottom Line: Although inconsistently defined, intermittent fasting (example 500 kcal/day for 2 days/week) and continuous dieting (~25% reduction in caloric intake daily) result in similar weight loss, usually ~5-9kg at 6 months-1 year. Discontinuation rates with both diets is up to ~60%.

Read Tool

#236 – It’s all in the details… or is it? Biosimilars versus biologics for inflammatory conditions

Bottom Line: For patients with rheumatoid arthritis, other inflammatory arthropathies, or inflammatory bowel disease, biosimilars and biologics have similar clinical outcomes and adverse events. Given the cost differences, starting patients with or switching to biosimilars should be encouraged.

Read Tool
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General

(13)

#248 – Hydrochlorothiazide and Squamous Cell Skin Cancer: Remember when hypertension was easy?

Bottom Line: Observational data suggest an association between hydrochlorothiazide and the risk of SCC. Causation has not been proven. Risk appears to consistently increase with dose and duration (example: 5 years of use increases risk 3-4 times). Baseline incidence of SCC is <0.1% annually. The same risk has not been established with thiazide-like diuretics (like indapamide or chlorthalidone). The benefit of switching from hydrochlorothiazide to another agent should be weighed against the risk of changing medications.

Read Tool

#247 – Fact or Fad: Intermittent fasting for sustained weight loss

Bottom Line: Although inconsistently defined, intermittent fasting (example 500 kcal/day for 2 days/week) and continuous dieting (~25% reduction in caloric intake daily) result in similar weight loss, usually ~5-9kg at 6 months-1 year. Discontinuation rates with both diets is up to ~60%.

Read Tool

#246 – Just wait a minute: Point-of-care testing for Group A Streptococcal pharyngitis

Bottom Line: Point-of-care testing, including rapid antigen detection tests and newer nucleic acid detection tests for GABHS pharyngitis are useful for ruling in a diagnosis of GABHS when positive (specificity 95%-99%). Nucleic acid detection tests may be more sensitive than rapid antigen detection tests (92% versus 85%). While immediate testing and treatment may not always be required, populations at increased risk of GABHS complications, such as Canada’s Indigenous populations, are more likely to benefit.

Read Tool

#245 – Taking a hard look at the evidence: Phosphodiesterase-5-inhibitors in erectile dysfunction

Bottom Line: PDE5 inhibitors increase the proportion of successful sexual intercourse attempts to ~65% versus ~30% for placebo. For every 3 men given a PDE5 inhibitor compared to placebo, an additional 1 will have “improved erections”.

Read Tool

#244 – Injecting Evidence into Platelet-Rich Plasma Injections

Bottom Line: The best quality evidence shows no difference in pain, function, or return to sport between platelet-rich plasma, dry needling, or saline for patients with Achilles tendinopathy, lateral epicondylitis, or rotator cuff tendinopathy.

Read Tool
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  • 3

General Surgery

(2)

#248 – Hydrochlorothiazide and Squamous Cell Skin Cancer: Remember when hypertension was easy?

Bottom Line: Observational data suggest an association between hydrochlorothiazide and the risk of SCC. Causation has not been proven. Risk appears to consistently increase with dose and duration (example: 5 years of use increases risk 3-4 times). Baseline incidence of SCC is <0.1% annually. The same risk has not been established with thiazide-like diuretics (like indapamide or chlorthalidone). The benefit of switching from hydrochlorothiazide to another agent should be weighed against the risk of changing medications.

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
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Geriatrics

(1)

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
  • Page
  • 1
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  • 1

Hematology

(2)

#242 – Putting the FUN in Fungi: Toenail onychomycosis treatments

Bottom Line: Up to 45-60% of patients on oral treatments (terbinafine best), 6-23% on topicals (efinaconazole best), and <10% on placebo will be “cured” after ~1 year. Topicals should be reserved for cases with minimal (≤20-40%) nail involvement.

Read Tool

#241 – “Who’s the fairest of them all?”: Topical treatments for rosacea

Bottom Line: For moderate-severe papulopustular rosacea, topical metronidazole, azelaic acid, and ivermectin have similar benefit with ~65-75% achieving patient reported improvement

Read Tool
  • Page
  • 1
  • of
  • 1

Infectious Disease

(1)

#246 – Just wait a minute: Point-of-care testing for Group A Streptococcal pharyngitis

Bottom Line: Point-of-care testing, including rapid antigen detection tests and newer nucleic acid detection tests for GABHS pharyngitis are useful for ruling in a diagnosis of GABHS when positive (specificity 95%-99%). Nucleic acid detection tests may be more sensitive than rapid antigen detection tests (92% versus 85%). While immediate testing and treatment may not always be required, populations at increased risk of GABHS complications, such as Canada’s Indigenous populations, are more likely to benefit.

Read Tool
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  • 1
  • of
  • 1

Neurology

(1)

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
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  • 1

Obstetrics-Gynecology

(2)

#238 – In COPD puffers, does three-of-kind beat a pair?

Bottom Line: In COPD patients with ≥1 exacerbation per year, triple therapy reduces the risk of having ≥1 exacerbations/year compared to LAMA/LABA dual therapy (one less patient for every 36) but increases the risk of pneumonia (one more patient for every 34) and costs. It is possible that higher blood eosinophil counts (>150-300 cells/µL) may help target adding ICS.

Read Tool

#237 – Verifying the Value of Vaginal Estradiol Tablets

Bottom Line: Vaginal estradiol tablets are likely no better than placebo vaginal gel for reducing “most bothersome symptom scores” (mainly dyspareunia). However, compared to placebo vaginal tablets, they reduce symptoms (example: treatment “success” at 12 months in 86% versus 41% placebo). A non-medicated vaginal gel may be reasonable first-line for dyspareunia.

Read Tool
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Oncology

(1)

#248 – Hydrochlorothiazide and Squamous Cell Skin Cancer: Remember when hypertension was easy?

Bottom Line: Observational data suggest an association between hydrochlorothiazide and the risk of SCC. Causation has not been proven. Risk appears to consistently increase with dose and duration (example: 5 years of use increases risk 3-4 times). Baseline incidence of SCC is <0.1% annually. The same risk has not been established with thiazide-like diuretics (like indapamide or chlorthalidone). The benefit of switching from hydrochlorothiazide to another agent should be weighed against the risk of changing medications.

Read Tool
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  • 1

Orthopedics

(1)

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
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Pediatrics

(1)

#239 – Need milk? Domperidone for increasing breast milk supply

Bottom Line: In mothers of pre-term infants, domperidone increases milk volume by ~90 ml more than placebo after 14 days, with an additional 1 in 5 women experiencing a 50% increase in milk supply. Doses above 30 mg/day are likely not needed and may increase the risk of arrhythmias. Optimal length of treatment unknown.

Read Tool
  • Page
  • 1
  • of
  • 1

Psychiatry

(2)

#243 – Spread the Word: Widespread Distribution of Naloxone to Decrease Opioid-Related Deaths

Bottom Line: Offering naloxone kits and overdose related education for people who use opioids and their community may decrease opioid related deaths by ~7 per 100,000 population over one year. Effectiveness is likely influenced by magnitude of opioid problem in a given community and other confounders (like co-ingestions, co-morbidities, type and dose of opioid used).

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
  • Page
  • 1
  • of
  • 1

Rheumatology

(3)

#244 – Injecting Evidence into Platelet-Rich Plasma Injections

Bottom Line: The best quality evidence shows no difference in pain, function, or return to sport between platelet-rich plasma, dry needling, or saline for patients with Achilles tendinopathy, lateral epicondylitis, or rotator cuff tendinopathy.

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool

#236 – It’s all in the details… or is it? Biosimilars versus biologics for inflammatory conditions

Bottom Line: For patients with rheumatoid arthritis, other inflammatory arthropathies, or inflammatory bowel disease, biosimilars and biologics have similar clinical outcomes and adverse events. Given the cost differences, starting patients with or switching to biosimilars should be encouraged.

Read Tool
  • Page
  • 1
  • of
  • 1

Urology

(3)

#245 – Taking a hard look at the evidence: Phosphodiesterase-5-inhibitors in erectile dysfunction

Bottom Line: PDE5 inhibitors increase the proportion of successful sexual intercourse attempts to ~65% versus ~30% for placebo. For every 3 men given a PDE5 inhibitor compared to placebo, an additional 1 will have “improved erections”.

Read Tool

#238 – In COPD puffers, does three-of-kind beat a pair?

Bottom Line: In COPD patients with ≥1 exacerbation per year, triple therapy reduces the risk of having ≥1 exacerbations/year compared to LAMA/LABA dual therapy (one less patient for every 36) but increases the risk of pneumonia (one more patient for every 34) and costs. It is possible that higher blood eosinophil counts (>150-300 cells/µL) may help target adding ICS.

Read Tool

#237 – Verifying the Value of Vaginal Estradiol Tablets

Bottom Line: Vaginal estradiol tablets are likely no better than placebo vaginal gel for reducing “most bothersome symptom scores” (mainly dyspareunia). However, compared to placebo vaginal tablets, they reduce symptoms (example: treatment “success” at 12 months in 86% versus 41% placebo). A non-medicated vaginal gel may be reasonable first-line for dyspareunia.

Read Tool
  • Page
  • 1
  • of
  • 1