We recap the top pearls from our SGIM & ACP 2021 highlight shows (including gabapentin for pain, LGBTQ and Women’s health pearls, CCBs and edema, MRSA swabs, IPMNs, DILI, and more!) plus recent interviews on bariatric surgery and osteoporosis. It’s Tales from the Curbside! (TFTC #6), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.
Note: No CME for this mini-episode but visit curbsiders.vcuhealth.org to claim credit for #275 Bariatric Surgery and #277 Bone Up on Osteoporosis.
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Click the links below for complete show notes.
Featuring The Curbsiders team and production and graphics by Sarah Phoebe Roberts
Matt’s Pearl – It’s PRIDE month. Let’s remember that pronouns matter. Ask: What name do you use/what do you like to be called? What pronouns do you use? Be sure the correct name and pronouns are used in the record. Use a trauma informed approach to the exam. For example: Explain why exam elements are necessary. If the patient is wearing a chest binder (for the desired appearance of a flatter chest), then one might say, “I think for us to do a safe exam we should probably listen to the lungs without the binder on, how do you feel about that?”.
Paul’s Pearl – Caring for Muslim patients:
For Muslim patients who fast during Ramadan, the International Diabetes Foundation IDF g/l was updated in 2021.
Also, some women’s health stuff:
Matt’s Pearl – Gabapentin is not helpful for acute or chronic perioperative pain (Systematic Review and Meta-analysis by Verret, 2020). It’s also not beneficial for chronic pelvic pain (GaPP2, Lancet 2020). Side effects include dizziness, drowsiness, and visual disturbances. It’s time we all acknowledge that gabapentin is not a panacea.
Matt’s Pearl – A negative Nasal Swab for MRSA within 7 days has a high NPV (high proportion of true negatives) and can be useful to rule out MRSA, and avoid anti-MRSA antibiotics. We used to think this only applied to pneumonia, but it turns out to have a high overall NPV 96.5% (range 93.1-99%) for urinary tract, intra-abdominal, bloodstream and wound infections. (Mergenhagen, Clin Inf Dis 2020).
Featuring The Curbsiders Team production by Matt Watto and Beth Garbitelli
Matt’s Pearl – SGLT2 inhibitors are now a heart failure drug (DAPA-HF), and have beneficial effects on kidney function (DAPA-CKD). Not surprisingly SGLT2 inhibitors are now recommended as first-line therapy for heart failure, and achieving target/maximally tolerated doses of ARNI/ACEi/PRB is not necessary before adding SGLT2 (2021 Update to ACC Guidelines). We are now awaiting the results of the EMPEROR-Preserved Trial to see if they are effective in HFpEF.
Paul’s Pearl – GI and Hepatology- Dr. William Sanchez. Intraductal papillary mucinous neoplasm-IPMNs can grow and progress to pancreatic cancer. However, surgical management is a Whipple procedure, a huge surgery even for otherwise healthy patients. Surveillance should be discontinued in patients who are not candidates for surgical intervention (expert opinion / common sense).
Drug Induced Liver Injury (DILI)–Many prescriptions and OTC meds can cause DILI. Most drugs have a signature toxicity pattern. Includes: cholestatic, hepatocellular, micro- or macrosteatosis, veno-occlusive disease, or drug-induced autoimmune hepatitis. No specific diagnostic test, but positive antinuclear and anti-smooth muscle antibodies suggest drug-induced autoimmune hepatitis (seen with nitrofurantoin, alpha-methyldopa, and hydralazine). Livertox.nih.gov is an excellent resource.
Matt’s Pearl – Watch out for prescribing cascades (i.e. loop diuretic prescribed for CCB associated edema). Many patients placed on CCB develop LE edema (Savage et al 2020). @Tony_Breu has a great Tweetorial on why ACE inhibitors are the better choice to prevent CCB associated edema. ACE inhibitors produce vasodilation in the pre AND post-capillary vessels. As a result, they are able to mitigate the increase in capillary pressure seen with CCBs.
With Dr. Vivian Sanchez. Production and graphics by Paul Williams and Edison Jyang.
Paul’s Pearl – Refer more patients to bariatric (aka metabolic) surgery. Mortality rates are <1% and it can achieve much higher levels of weight loss than lifestyle changes, or medications for obesity. Patients often lose 60-70% of excess weight (often 60-70 lbs or more). Most centers have a dietician and behavioral psychologist who work alongside the surgeon to coordinate perioperative care.
Patients can expect improvements in quality of life and mortality. Metabolic changes occur shortly after surgeries are performed. The exact mechanisms are not well-understood. Patients with diabetes can sometimes be discharged off of diabetes medications.
Matt’s Pearl – Monitoring after bariatric surgery includes more frequent monitoring in the first 12 months for CBC, CMP, iron, lipids, a1c, TSH, thiamine (B1), B12 +/- homocysteine, or MMA. Additional tests to consider are Vit D, iPTH, Vit A, E, K, zinc, copper, and selenium especially early on after RYGB or biliopancreatic diversion (Table 11-14 in AACE 2019 guidelines).
Paul’s Pearl – Abdominal pain in the postoperative period of gastric bypass needs to be evaluated urgently. Complications include symptomatic cholelithiasis, marginal ulceration, or dilated remnant. Gastric sleeve patients are at increased risk for worsening reflux, as well as Barrett’s esophagus even without reflux symptoms–Dr. Sanchez recommends upper endoscopy after 3 years to evaluate for this.
With Dr. Carolyn Crandall. Production and graphics by Isabel Valdez
First let’s define terms (AACE, 2020):
“patients with low bone mass (osteopenia) or low bone mass defined as T-score between −1.0 and −2.5 based on BMD testing, but with a low-trauma (fragility) fracture of the spine, hip, proximal humerus, pelvis, or possibly distal forearm, are also at an increased risk for future fractures and should be diagnosed with osteoporosis and considered for pharmacologic therapy”
Calcium intake should be assessed, but supplementation is not mandatory. AACE guidelines recommend total daily calcium intake from all sources of 1200 mg. Dr. Crandall recommends checking 25-OH vitamin D and repleting to a level of at least 20 before starting therapy for osteoporosis. Dr. Crandall stressed that screening (asymptomatic adults) for 25-OH Vit D deficiency is not recommended. The National Academy of Medicine recommends a specific daily intake by age and gender (typically 400 to 800 units daily). Higher levels are commonly given during the treatment of Vitamin D deficiency.
Matt’s Pearl – Workup for osteoporosis: Think about multiple myeloma, thyroid, celiac, steroid use, Cushing’s. Check CMP, TSH, Ca2+, 25-OH Vit D, iPTH in all patients. Technically a 24-hour urine test is recommended [per AACE, 2020].
“It should be noted that a 24-hour urine calcium collection is the best commercially available method of evaluating adequacy of calcium intake and absorption.”
Paul’s Pearl – Go with the lowest score on the DXA report osteoporosis vs low bone density. Serial bone density monitoring is not recommended. Do not measure bone density while patients are on a standard course of therapy (5 years oral or 3 years IV bisphosphonate; or denosumab). At that time obtain a DXA and decide whether to pursue a drug holiday or continue therapy. Changes in bone mineral density of 3-6% at the hip or 2-4% at the spine could be due to the precision error of the test itself, and it is recommended that repeat measurements use the same machine. The report itself should comment on if there is a significant change from prior.
Matt’s Pearl – Be very careful when stopping denosumab. Bone density falls off quickly (Tsourdi, JCEM 2021, Lyu, Annals 2020). Is this a bridge to nowhere? Destination therapy? Unfortunately, we don’t have great guidance about how to treat patients with advanced CKD especially if they are stopping denosumab.
Matt’s Pearl – Osteonecrosis of the jaw is rare and can occur with bisphosphonates or denosumab. The AACE guidelines have helpful figures to illustrate relative risks (see Suppl1 Figure 2: A, B, C in 2020 AACE guidelines)
Listeners will review tops pearls from recent curbsiders episodes
After listening to this episode listeners will…
Drs. Watto and Williams report no relevant financial disclosures.
Watto MF, Williams PN. “#282 Bariatric Surgery, Osteoporosis, 2021 Conference Highlights! (TFTC #6)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date June 30, 2021.
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