We recap the top pearls from 2021, including celiac disease, kidney stones, SGLT2 inhibitors for weight loss & HFpEF, smoking cessation, buprenorphine for acute pain, metabolic alkalosis, nephrotic syndrome, bronchiectasis, obesity hypoventilation syndrome, acute diarrhea, osteoporosis, and diabetes. Plus, Paul and Watto express their gratitude to The Curbsiders family and look forward to 2022. Finally, it’s our annual recap extravaganza 2021 with guest host Chris “the Chiu Man” Chiu (@cjchiu), providing a rapid review of previous Curbsiders episodes for your spaced learning.
Special thanks to the whole Curbsiders team and our listeners for an incredible six years of podcasting!
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Garbs’ picks: Pelvic pain, smoking cessation
Addiction medicine pearls: Nicotine use disorder; Acute pain in OUD
Cardiology: Peripheral arterial disease (PAD), SGLT2 inhibitors for HFpEF
Pulmonology: Bronchiectasis, OHS
Gastroenterology: Celiac disease, Liver test abnormalities
Bariatric Medicine: Semaglutide for weight loss; bariatric surgery
Endocrinology: Osteoporosis; Diabetes FAQ
#311: Pelvic Pain – Perform a trauma-informed pelvic exam. Establish trust and give the patient control.
#252: Smoking Cessation (Varenicline has been recalled by Pfizer (FDA.gov 9/16/2021). Apo-varenicline is substituted by some pharmacies). A time to first cigarette of under 30 minutes implies a heavier use disorder so choose the higher dose (typically 4 mg) nicotine gum. (Heatherton, 1989)
#267: Chronic Diarrhea – Osmotic Diarrhea will resolve with fasting.
#299: For patients with OUD hospitalized with acute pain: Buprenorphine given every 6-8 hours may help their pain, but full agonist opioids are often necessary as add-on therapy. Partner with the patient’s surgeon to create a perioperative pain plan and avoid a withdrawal period.
Apply for your x-waiver now! The buprenorphine training requirement has been waived (SAMSHA 2021).
#298: Kidney Stones. Use relaxation techniques and NSAIDS to pass a stone. Hydration (96 oz), low Na+, low animal protein, and pairing oxalate-rich foods with dietary calcium helps in stone prevention. Citrus fruits, potassium citrate supplements, thiazide diuretics, and bisphosphonates all favor prevention.
#250: In nephrotic syndrome, an Anti-PLA2R Ab titer might clinch the diagnosis for idiopathic membranous nephropathy, but most patients will need a biopsy to determine the cause. Consider using amiloride for edema in nephrotic syndrome! Amiloride addresses plasmin activation of ENaC channels leading to volume-independent sodium retention (Henrichs 2018)!
#308: Metabolic Alkalosis. Be aggressive with potassium chloride repletion during acute CHF admission for diuresis. Acetazolamide 500 mg bid often lowers serum bicarb by six points but makes carbonated beverages taste disgusting! Follow the urine pH during treatment. Bicarbonaturia = success!
#260: Peripheral arterial disease: ABIs (+/- treadmill), and toe pressures can make the diagnosis. Pursue advanced imaging and angiography if critical limb ischemia is present or if patient fails conservative management. Tell the patient to walk 30-45 minutes each day with breaks as needed, and aggressively treat ASCVD risk (DM, HTN, lipids, aspirin 81 mg daily, smoking cessation).
#307: Spooky Tofurkey Cakes. SGLT2 inhibitors for HFpEF (especially, HFmrEF) reduce heart failure hospitalizations and the rate of renal dysfunction (Anker 2021). We suspect this is a class effect, but the DELIVER Trial of Dapagliflozin for HFpEF will confirm.
#306: Consider bronchiectasis in patients with chronic cough, multiple bouts of pneumonia, or COPD in a nonsmoker. Patients are rarely treated for MAC unless they have weight loss.
#269: OHS is a diagnosis of exclusion (TTE, CXR, PFTs = basic workup). Bicarb under 27 has a good NPV. CPAP monotherapy is adequate for most. Don’t use oxygen monotherapy! Weight loss is critical.
#275: Obesity increases mortality. Bariatric surgery has a mortality rate of <1% and a long-term mortality benefit vs. usual care (Carlsson, 2020). Post-op life expectancy is also increased, especially in patients with diabetes (Syn, 2021). Don’t forget to avoid extended release meds post-op and monitor for vitamin deficiency (AACE et al guidelines 2020)!
#264: Semaglutide 2.4 mg weekly plus usual care achieved nearly 15% weight loss at 68 weeks vs. ~2.5% with usual care plus placebo (Wilding, 2021). Unfortunately, weight gain may occur once semaglutide is stopped (Rubino, 2021). Interestingly, semaglutide 2.4 mg weekly provided significantly more weight loss than the 1 mg dose (max dose approved for diabetes) but similar hemoglobin A1C lowering effects (Davies, 2021).
#293:RAHUL GANATRA’s Pearl: A transient rise in hepatic enzymes in the setting of abdominal pain can signify a gallstone that passed or one that is “ball-valving” and causing temporary obstruction!
#300: In Celiac disease, it’s okay to use Deamidated Gliadin Peptide (DGP) Ab or Endomysial Ab if indeterminate tissue transglutaminase (TTG) IgA. A biopsy is necessary for most. Patients shouldn’t be on a gluten-free diet during testing. After diagnosis, screen first-degree relatives, trend titers, repeat biopsy in 2 years, and check a baseline DXA in adult patients!
#277: Osteoporosis. Obtain bone mineral density testing after 3-5 years of IV (zoledronic acid) or oral (alendronate or risedronate) bisphosphonate, respectively, and decide on drug holiday vs. continued therapy (Qaseem, 2017). Beware of the rapid drop in BMD after missing doses or stopping denosumab (Lyu, 2020; Tsourdi, 2021).
#296: Diabetes FAQ. Check non-fasting glucose and C-peptide to help determine T1DM vs. T2DM (Leighton, 2017). Consider T1DM testing (GAD 65, Beta Islet cell, Insulin Antibodies) for anyone in their 30s or younger because BMI alone is unreliable. Metformin and long-acting insulin (LAI) can be used as a starting regimen since basal-bolus regimens often have complexity, cost, and adherence issues (expert opinion). Further, reevaluate your patients with diabetes. Many could benefit from LAI plus SGLT2i or GLP-1 agonists instead of a basal-bolus regimen!
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