CCFP Topic: Periodic Health Assessment – Part 2

Another weak recommendation here – meaning shared decision-making with your patients, but guideline recommends offering a one-time screening abdominal ultrasound for all males aged 65-80. Note that this recommendation does not apply to women, who are less likely to have a triple A.

We will be referencing the 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada, which was developed by Osteoporosis Canada. Provincial guidelines may vary slightly, but this is the guideline recommended by the CTF. A link to the Osteoporosis Canada Quick Reference Guide can be found… you guessed it, in the show notes. It has a lovely flowchart that summarizes most of what we’re about to say.

So, question one: who gets screened? [pause] So there are really three main demographics:

1. All men and women age 65 and older
2. Menopausal women and men age 50 to 64 with clinical risk factors for fracture. You can simplify this into all individuals aged 50-64, since that ends up being around the age of menopause.
3. Adults aged < 50 with even bigger risk factors. We’ll call these mega-risk factors.

MEGA RISK. I’m going to add some crazy vocal effects in post. So there is a laundry list of regular risk factors (ie, those that would warrant testing in the 50-64 group), see if you can list off a few.

Risk factors include: – Fragility fracture after age 40 – Prolonged glucocorticoid use (ie, greater than 3 months) and Other high-risk meds (like aromatase inhibitors and androgen deprivation therapy) – Parental hip fracture – Vertebral fracture or osteopenia identified on X-ray – Current smoking – High alcohol intake – Low body weight (< 60 kg) or major weight loss (>10% of weight at age 25 years) – Rheumatoid arthritis – And other disorders strongly associated with osteoporosis, of which there are many, mostly in the rheumatologic/autoimmune realm.

The MEGA RISK factors, which would warrant screening in individuals under the age of 50. So these mega risk factors include

• Fragility fracture
• Prolonged use of glucocorticoids (also 3 months) or other same high-risk medications
• Hypogonadism or premature menopause
• Malabsorption syndrome
• Primary hyperparathyroidism and
• Other disorders strongly associated with rapid bone loss and/or fracture.

We didn’t actually touch on HOW we screen yet, which is with Bone mineral density testing.

Once you’ve calculated the BMD score, you’ll plug it into a validated risk calculator like FRAX or CAROC which stratifies patients into low, moderate, or high risk, based on their 10-year fracture risk as a percentage.

Low risk (ie < 10% risk) don’t need pharmacotherapy, re-screen again in 5 years.

High risk does qualify, High risk defined as > 20% risk or prior fragility fracture of the hip or spine or more than one fragility fracture anywhere else.

Moderate risk (ie, 10-20%) would likely benefit from pharmacotherapy only if they have an additional risk factor or vertebral fracture identified on Lateral spine x-ray (T4-L4). In the absence of those risk factors, consider repeat screening in 1-3 years.

Before moving on, don’t forget to Encourage basic bone health for all patients, regardless of risk, which should include regular active weight bearing exercise, calcium, vitamin D, and fall prevention strategies.

The specific guideline refers to chlamydia and gonorrhea, since they are tested together. So, another question to the listener: who gets screened, and how often? 

The Force makes conditional recommendation based on very low certainty evidence in favour of opportunistic screening for all average risk sexually active individuals under 30 years of age. This could mean annually, but recognize that many of these young folks may not be coming in that frequently – and so that’s where the opportunistic part comes in (ie, ask them about it when they’re visiting for something else). In terms of test type and collection method – we’re looking at NAAT via self- or clinician-collected cervical or urine testing in women and urine testing in men.

Their guideline emphasizes the average risk part.

High-risk includes:

• having multiple sexual partners,
• previous STI’s or having sex without a condom, among others.
• This would warrant more frequent screening, and should also include HIV, syphilis, Hep B and Hep C.

We’re also not including pregnant patients in this population – since they have their own specific guidelines. Also, it doesn’t include people over 30, because apparently they don’t have sex, according to the Force. So there’s that to look forward to. As a brief aside, in BC we actually have a cool resource called getcheckedonline.com that lets you test yourself for chlamydia, gonorrhea, HIV, syphilis, and Hep C, without going to the doctor – really gets rid of those barriers Other provinces may have their own version, worth looking into.

Current Canadian guidelines are based on the Diabetes Canada clinical practice guidelines, which were updated in 2020.

Now, caveat, the Force also has their own set of guidelines, which are from 2012 (aka a full decade ago) – but Diabetes Canada is generally considered the gold standard… sorry the Force.

Another point goes to Diabetes Canada for their incredibly high yield 7-page quick guide.

Ok so first question, who gets screened? Take a second to think about it…

Diabetes Canada divides it into three main demographics:

• Age <40 years or low-moderate risk.
• Age ≥40 years or high risk* (which they call at least a 33% chance of developing type 2 diabetes within 10 years) and
• very high risk (which is 50% chance of developing type 2 diabetes within 10 years).

So for how, we’re looking at A1C and fasting plasma glucose as our most ideal initial tests, ideally done together. In terms of how often, Age <40 years or low-moderate risk does not need any screening, Age ≥40 years or high risk should get screened every 3 years, and the very high risk folks should get screened every 6 to 12 months. My turn to ask a question, Braedon – what are those golden diagnostic numbers?

We’re looking at an A1c of 6.5 or above and a FPG of 7.0 or above as diabetes range. If A1c is 6 to 6.4, we call that prediabetes, and if FPG is 6.1 to 6.9, we call that impaired fasting glucose.

So notice how I said diabetes range and not diabetes. As you’ll probably know, you cannot diagnose diabetes if only one of A1c or FPG  is in the diabetes range – unless of course they have symptoms of overt hyperglycemia (the polys, uria, dipsia, phagia), in which case you can. If they’re asymptomatic and only A1C or FPG are in the diabetes range, you would repeat that same test (the elevated one) as a confirmatory test. No need to wait 3 months for the A1C repeat if its elevated, we’re simply looking to make sure there wasn’t a false positive due to lab error or other factors that affect A1C accuracy.

Adding to that, If both A1C and FPG are in the diabetes range, diabetes is confirmed. Something else worth saying is that even if you don’t diagnose diabetes, if you see pre-diabetic or at-risk range lab values, you should be testing more frequently since that would automatically make them higher risk of progression. Other risk factors for diabetes are pretty straightforward, things like having a first-degree relative with type 2 diabetes, high risk populations (low socioeconomic status, essentially any ethnicity other than caucasion), cardiovascular risk factors, presence of end organ damage associated with diabetes (AKA the “-opathies” neuropathy, retinopathy, nephropathy), and a big laundry list of conditions and medications associated with diabetes.

hyperlipidemia/dyslipidemia, usually used interchangeably even though there are slight unimportant differences. We’re using the Canadian Cardiovascular Society’s Dyslipidemia guidelines, which were updated in 2021. They also have their pocket guideline available online, it’s super to-the-point, which you know I love.

Now, Canadian Family Physician journal also put out guidelines, back in 2015, which they call “Simplified Lipid guidelines” – which based on the name, already sounds more fun than the CCS guidelines. Their team actually included input from family physicians, AKA the people typically implementing these recommendations, imagine that – so we’ve also included a link to that paper in the show notes. Ultimately, pick one that works best for you. Thankfully they’re pretty similar, nearly identical in fact – we’ll let ya know where they diverge. So, question numero uno, who gets screened and how?

So you should be grabbing a standard non-fasting lipid panel (total cholesterol, triglycerides, LDL, HDL, non-HDL) for average risk men and women aged ≥40 years or postmenopausal women. The CFP recommends 50+ for women, so pretty similar. In either case, we generally stop screening at age 75. Consider starting your screening a bit earlier in higher risk ethnic groups such as South Asian or First Nations individuals. CCS also suggest throwing on renal function with an eGFR. They also really love that lipoprotein(a)— and recommend screening with it once in a patient’s lifetime, typically with their initial screening. Finally, you can consider optional screening with urine ACR (if eGFR <60, hypertension, DM) or an Apo-B level.

There’s also a laundry list of higher risk individuals who should get screened regardless of age. No real surprises in this list, so I’m gonna read it rapid-fire:

• current cigarette smoking,
• diabetes,
• hypertension,
• erectile dysfunction,
• chronic kidney disease,
• essentially any inflammatory/rheumatologic disease,
• HIV,
• COPD,
• clinical evidence of atherosclerosis,
• AAA,
• clinical manifestations of DLD like xanthomas, BMI>30, or
• a first-degree relative with premature cardiovascular disease or hyperlipidemia (which is Men under 55 and women under 65)

Once you’ve grabbed that lipid panel, go on and plug it into a validated risk score calculator, most people use Framingham but there are others that exist. In any case, you should 100% use CVDcalculator.com, I love it. It was developed by the legendary pharmacist, UBC professor, and BS Medicine podcast co-host James McCormack. It’s got little smiley faces that make it easier for you and your patients to visualize their risk, and lets you tick off interventions like exercise, mediterranean diet, statins, and other stuff to see how much it would reduce their risk.

So, pick your calculator, plug in those lipid numbers and some other patient info, and you’ll get a 10-year CVD risk. Once you have that, you can split your patient into one of three groups, low risk (under 10% 10-year risk), moderate risk (10-19%), or high risk (20% and up). So, what do we do for these folks?

As with most risk stratification tools, low and high risk are fairly straightforward. If they’re low risk, recommend the routine lifestyle stuff and screen ‘em again in 5-years (or sooner if they develop some other risk factor). CCS breaks this down even more and suggests annual screening for a FRS ≥5% and 5-years if below that.

For the high risk folks, you should be considering a high-potency statin like 40-80 of atorvastatin or 20-40 of rosuvastatin, in addition to the usual lifestyle stuff. Atorva’s usually better tolerated, but for either one, start at a lower dose and work your way up as tolerated. Other high risk peeps who automatically get a statin are those with LDL ≥5.0, most type 2 diabetics, most CKDers, and anyone with major cardiovascular disease, so things like MI, stroke/tia, PAD/claudication, CAD, or AAA.

Moderate risk is where it gets into the weeds a bit, so consider statin if they are moderate category PLUS have some other high risk feature, which is where the CCS guidelines give a bunch of specific numbers and specific risks. Honestly, just look it up, it’s kind of dense. The CFP simplified guidelines, on the other hand, simply suggest discussing a moderate-potency statin with the patient. Shared decision-making, imagine that. This is where CVDCalculator.com really pulls its weight, since you can actually show them the relative benefit of a statin compared to, say, exercise or diet.

we’re not going to talk directly about the routine childhood vaccine series, since that’s not a part of the periodic health assessment, but keep in mind that some of the adult recommendations will change based on whether someone has had their childhood series or not, which is pretty common sense. In any case, make sure you’re confirming that your patients have had their childhood series – because many may not, particularly if they have immigrated to Canada. Records should be available through public health, which patients can also access themselves.

Another caveat, immunization is its own priority topic! We don’t yet have an immunization episode written, (consider this a call to action for a brave listener who would be interested in helping write it with us), but as with other topics, we’ll cover the bare bones essentials today. We’re using RxFiles as our main resource, it’s commonly free to access via your hospital and highly recommended.

Alright, I’m feeling a bit of back and forth for this one. To the listeners, try and come up with the answer on your own. Caleb, you ready?

Ready as I’ll ever be.

Alright, adult immunization guidelines. And away… we… go:

Tetanus/Diphtheria (aka Td) plus or minus pertussis (aka Tdap).
So the Td is a booster every 10y, or a 3-dose primary series for the unimmunized. The Tdap adds pertussis, which should be thrown in as a single one-time dose to all adults and once during pregnancy regardless of vaccination status. Some jurisdictions may offer Tdap every 10 years as opposed to Td, which is also totally fine.

What about the Pneumococcal vaccine?
This is a single dose of the 23-valent vaccine (aka PNEUMOVAX-23) for everyone ≥65yo or <65 for higher risk, especially things like COPD/asthma or immunocompromised in some way. You may also see the three-dose 13-valent series (aka PREVNAR-13) floating around. It’s not covered unfortunately, but you can consider it for those aged 65 years and older if they really want it, or to any adult with risk factors like smoking, alcohol use disorder, homelessness, and chronic medical conditions.

Influenza Vaccine
Annually, for everyone – including children 6 months and up and pregnant women. Especially now. We’re seeing some pretty scary stuff this flu season, so really strongly encourage your patients to get their jabs if they haven’t.

What about HPV?

There used to be age limits, but no longer. Nowadays, the Public Health Agency of Canada recommends the HPV vaccine be administered to all adults who are at ongoing risk of exposure to HPV (aka the sexally active). There is no upper age limit, 30 year olds rejoice. That said, it is most ideally given before the onset of sexual activity.

Children should routinely get offered the HPV9 vaccine (aka GARDASIL®9) in grade 6 as a 2-dose series over 6 months. For anyone 15 and up, you’ll need 3 doses over 6 months. In most provinces it should be partly or fully covered for people aged 26 and under. Still could be worth getting beyond age 26, especially if you have ongoing risk.

Quick shout out to the HPV vaccine, this is literally a vaccine against cervical cancer and genital warts, and other less-common HPV associated cancers as well, like head and neck or anal cancers. It’s the bomb.com. Or dot ca.

Measles, mumps, rubella, MMR.
This is part of the childhood vaccine series, so if you’ve had that already, you’re good. For unvaccinated adults born in or after 1970 or those at higher risk of exposure (like healthcare workers or travelers), offer a 2-series dose. Anyone born before is considered to have natural immunity.

What about varicella?
The ol’ chicken pox. I’m old enough to remember having a pox party, where we got together with our infected friends and drank out of the same glass and rubbed our faces together. Kinda gross. Thankfully we don’t have to do that anymore thanks to the MMR-V vaccine childhood vaccine series. It’s also offered in grade 6 for the unvaccinated. For the rest of us, it’s recommended to get that 2-dose series if you’re <50 years old and are not vaccinated or didn’t get chickenpox. But now.. This begs the question.. What do we do if they’re 50 years or older?

The ol’ chicken pox. I’m old enough to remember having a pox party, where we got together with our infected friends and drank out of the same glass and rubbed our faces together. Kinda gross. Thankfully we don’t have to do that anymore thanks to the MMR-V vaccine childhood vaccine series. It’s also offered in grade 6 for the unvaccinated. For the rest of us, it’s recommended to get that 2-dose series if you’re <50 years old and are not vaccinated or didn’t get chickenpox. But now.. This begs the question.. What do we do if they’re 50 years or older?

So this is the basically the same vaccine as varicella but its inactivated (aka killed) as opposed to live attenuated. You probably know it as Shingrix. It’s recommend for all immunocompetent persons ≥50 years old, with better evidence for those 60 and up, even if they’ve already had shingles (though you should wait at least 1 year after they had shingles). Folks who had the older vaccine called Zostavax are also included in the recommendation. Unfortunately its not covered in most places for most groups. To finish it off, any other potential vaccines we should think about?

Nothing routine, but higher risk and/or unvaccinated people may benefit from meningococcal, Hep A, and Hep B vaccines. As healthcare workers, we’re required to have the Hep B vaccine. And with that… Caleb.. I think we’ve done it.

Update to the Preventive Care Checklist Form© | The College of Family Physicians of Canada (cfp.ca)

Explanations for the Preventive Care Checklist Form (cfpc.ca)

OC_quickref_1309v1 (osteoporosis.ca)

2013-osteoporosis-en.pdf (canadiantaskforce.ca)

Chlamydia and Gonorrhea—Clinician FAQ – Canadian Task Force on Preventive Health Care

CPG_Quick_Reference_Guide_EN_2021.indd (diabetes.ca)

The Canadian diabetes risk questionnaire (healthycanadians.gc.ca)

90364 CCS – Dyslipidemia 2022 rev5

857.full.pdf (cfp.ca)

Risk Calculator (cvdcalculator.com)

Vaccines | RxFiles

Vaccination for adults – Canada.ca