What's new in primary care

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

SCREENING

Screening for alcohol use during pregnancy (February 2023)

Although universal screening for alcohol use during pregnancy is advised, evidence suggests that screening and follow-up care remain suboptimal. An analysis of 2017 and 2019 United States Behavioral Risk Factor Surveillance Systems data noted that approximately 20 percent of pregnant patients were not asked about alcohol consumption at their most recent visit and, of those who were asked and reported alcohol use, only 16 percent were advised to stop or reduce their consumption [1]. We advise continued education for both patients and clinicians about the risks of alcohol use during pregnancy and encourage universal screening for pregnant persons. (See "Alcohol intake and pregnancy", section on 'Screening during pregnancy'.)

IMMUNIZATIONS

Updated immunization schedule for adults in the United States (February 2023)

The 2023 United States Advisory Committee on Immunization Practices (ACIP) vaccination schedules for adults have been published by the Centers for Disease Control and Prevention (CDC) (figure 1 and figure 2) [2]. Changes include recommendations for COVID-19 vaccination, quadrivalent influenza vaccine in persons aged ≥ 65, pneumococcal vaccines in previously vaccinated individuals, and poliovirus vaccination for individuals at increased risk of polio exposure. Clarification has been added that zoster vaccination does not require serologic evidence of prior varicella infection. Newly approved vaccines have been included as well (eg, PreHevbrio for hepatitis B and Priorix for MMR vaccination). Healthcare providers in the United States should review these recommendations to guide their vaccination practices for adult patients. (See "Standard immunizations for nonpregnant adults", section on 'Immunization schedule for nonpregnant adults'.)

GENERAL INTERNAL MEDICINE

Therapeutic inertia in older adults with uncontrolled blood pressure (March 2023)

Therapeutic inertia, defined as the failure by clinicians to intensify antihypertensive treatment when blood pressure rises or remains above therapeutic goals, is an important contributor to low rates of hypertension control in the population. A large population-based study examined rates of antihypertensive initiation (or antihypertensive intensification) in older adults in the United States who had an ambulatory care visit in which their blood pressure was above goal (according to the American College of Cardiology/American Heart Association guidelines) [3]. In 2018, appropriate initiation of antihypertensive medication among untreated individuals occurred in less than 20 percent of visits, and appropriate addition of another antihypertensive agent among those already treated occurred in less than 10 percent of visits, representing a decrease in prescribing compared with data from 2008. These findings indicate that therapeutic inertia continues to be a major impediment to attaining hypertension control. (See "The prevalence and control of hypertension in adults", section on 'Methods to improve control rates'.)

Non-nutritive sweetener associated with adverse cardiovascular outcomes (March 2023)

Consumption of non-nutritive sweeteners may increase the risk of adverse cardiovascular outcomes through diverse mechanisms. Erythritol is a naturally derived sugar alcohol commonly used in processed foods, the consumption of which may increase platelet reactivity and thrombosis formation. In a discovery cohort of over 1000 patients, greater blood levels of erythritol were associated with increased three-year risk of major cardiovascular outcomes [4]. While further studies are needed to establish risks, patients should be aware of consumption of this additive in commonly consumed foods. (See "Overview of non-nutritive sweeteners", section on 'Specific health outcomes'.)

Removal of X-waiver requirement to prescribe buprenorphine for opioid use disorder (February 2023)

Previously, in order to prescribe buprenorphine for opioid use disorder (OUD) in the United States, clinicians had to apply for a federally required DATA Waiver (X-Waiver). In January 2023, the Consolidated Appropriations Act of 2023 removed this requirement and allowed clinicians with schedule III authority on their Drug Enforcement Administration (DEA) registration to prescribe buprenorphine for OUD treatment if permitted by applicable state law [5]. We believe this change will encourage buprenorphine prescribing and thus prevent opioid overdose. (See "Acute opioid intoxication in adults", section on 'Prevention of recurrent opioid overdose'.)

Vitamin D trials do not show benefit for COVID-19 outcomes (October 2022)

There is growing interest in the role of vitamin D as a facilitator of the innate immune response during SARS-CoV-2 infection. However, two recent trials evaluating the effect of vitamin D supplementation on COVID-19 outcomes did not show a benefit:

●In a trial from the United Kingdom, in which 6200 adults were randomly assigned to testing of serum 25-hydroxyvitamin D followed by daily low (800 units) or high (3200 units) dose vitamin D supplementation when the concentration was