We recap the top pearls from ACP #IM2022 including important drug interactions/intolerance (acetaminophen, tramadol, ticagrelor, nirmatrelvir-ritonavir), perioperative medicine (bridging, DOAC reversal agents, dental procedures, MINS), recognizing PMR, when to initiate urate-lowering therapy in gout, glucocorticoid-induced osteoporosis, food as medicine, dietary potassium, OSA, nocturia, telemedicine and health equity, a new obesity medicine paradigm, advances in HIV/PrEP, and rethinking atrial fibrillation!
Note: Due to a rapid turnaround there is no CME for this episode, but visit curbsiders.vcuhealth.org to claim credit for past episodes.
Common drug interactions (acetaminophen, ticagrelor, tramadol, Nirmatrelvir-ritonavir)
Perioperative medicine (bridging, DOAC reversal agents, dental procedures, MINS)
Nocturia and OSA
Food as Medicine
Rheumatology (how to diagnose PMR, when to initiate ULT for gout and steroid-induced osteoporosis)
Avi’s pearls on (diversity, telemedicine, telehealth, burnout)
Obesity medicine (a new paradigm and a new medication)
HIV in primary care (PrEP, long-acting injectable antiviral therapy)
Go slow when tapering long-term stable opioids (at least 50 mg morphine equivalent per day for more than 12 months). A retrospective study of commercial and Medicare Advantage plans over 100,000 patients found higher overdose rates (6.3/100pt years vs 4.9 in the tapered group) and higher rates of mental health crisis with depression/anxiety/suicide attempts. More rapid tapers (exceeding 10% per month) were associated with more complications (Angoli 2021).
Acetaminophen: Regular use of 4gm/day causes approximately a 5mmHg BP elevation in patients with hypertension (MacIntyre 2022).
Even at 2gm/day dose, Acetaminophen raises INR in patients on warfarin. (Parra 2007)
Ticagrelor can cause dyspnea, requiring discontinuation of the medication in about one in 20 patients. While not dangerous, this can be uncomfortable. (Ortega-paz 2007)
Tramadol (aka tramadont) has been associated with risk of hypoglycemia requiring hospitalization within the first 30 days with OR 2.6 for new tramadol vs new codeine prescription. (Fournier 2014). New prescription dispensation of tramadol, compared with codeine, was significantly associated with a higher risk of mortality, cardiovascular events, and fractures (Xie 2021)
Nirmatrelvir-ritonavir dose adjustments for drug interactions should be continued for at least 3 days after the last dose (so at least 8 days total)! (Liverpool Drug Interactions, 2022)
The DENTST study (2020) found no major bleeding during dental extractions when patients continued DOACs or Warfarin! So continue anticoagulation for patients during dental extractions (even multiple).
A reminder that the BRUISE CONTROL trial showed that there’s a higher risk of pocket hematoma during ICD/PPM placement with heparin bridging vs therapeutic warfarin (so don’t bridge–just continue the warfarin!)–and BRUISE CONTROL-2 found that continuing DOACs doesn’t increase the risk of hematoma.
PERIOP-2 is the latest to look at post-operative bridging, with further evidence against bridging–potentially even in some mechanical valve patients.
What about aspirin for secondary prevention in the perioperative setting? ACC/AHA gives conflicting recommendations, but expert Dr. Andrew Dunn’s opinion is that the data supports holding, especially for major surgery (source: session at ACP #IM2022)!
Beware of using Andexanet Alfa for reversal of the Xa inhibitors in bleeding events, as the reversal agent can wear off before the drug does, and patients may require a second dose of the $24,000 medication. Moreover, per the 2019 NEJM study results, ten percent of patients had thrombosis within 30 days of receiving the reversal agent.
MINS (myocardial infarction after noncardiac surgery) is common (maybe up to 20% of those having inpatient surgery) and predicts increased mortality (Botto 2014, Smilowitz 2020). Most patients are asymptomatic. Consider MINS the same as a positive stress test (expert opinion) and act to mitigate CV risk (AHA MINS sci statement 2021)
There are many tools to evaluate the amount of distress and impairment from nocturia (including the N-QOL instrument).
The prevalence of nocturia in patients with OSA is high (75% per Vrooman 2020). CPAP initiation led to a decrease in nocturia in almost half of patients, with improved quality of life. Think about testing for OSA in patients with nocturia.
For nocturia, there is an FDA-approved desmopressin analogue, but there were several episodes of severe hyponatremia in the elderly population–the population the most likely to suffer from nocturia–and the frequency of screening sodium was every other week in the trial (Fralick 2019). Behavioral strategies and pelvic floor physical therapy are still first line.
Food As Medicine
Bullets #2-6 below were gleaned from Dr. Michelle McMacken’s (@drmcmacken) at ACP #IM2022
Dietary potassium inhibits the target of thiazide–and using salt substitutes can lower blood pressure and the risk of cardiovascular events, per the 2021 SSaSS trial data.
Screen patients for food insecurity.
Improve health outcomes by replacing animal-based proteins with plant-based proteins.
Nutritionists agree: Green box foods are good (whole grains, legumes, fruits, vegetables, nuts, seeds)! Red box foods (processed meats, red meats, added sugars, refined grains, ultra-processed foods) are not good!
Having red wine with a cheeseburger does not constitute a Mediterranean diet!
Artificial sweeteners might be considered harm reduction for someone not yet ready to drink plain water instead (expert opinion).
Polymyalgia rheumatica (PMR) almost always features bilateral shoulder aching (Mahmoud 2020 ). Diagnosis (EULAR/ACR) requires age above 50, bilateral shoulder aching, and elevated ESR or CRP (Dasgupta 2012).
Gout: Consider urate-lowering therapy (ULT) after a 1st gout flare if any of the following: CKD 3 or greater, uric acid above 9 mg/dL, or history of urolithiasis (ACR Gout guideline 2020)
Glucocorticoid-induced osteoporosis: Bone loss occurs early (Laan 1993). Check bone density for anyone on more than 2.5 mg prednisone for more than three months and treat if FRAX score predicts moderate risk or higher (ACR Osteoporosis guideline 2017).
Dr. Quinn Caper’s keynote: Diversity improves impact in research. Ex. “ethnic diversity resulted in an impact gain of 10.63% for papers, and 47.67% for scientists” (AlShebli 2018)–the authors explored the association between research impact (# citations) and several types of diversity (ethnicity, diversity, gender, affiliation, academic “age”). Ethnic diversity had the strongest impact.
Dr. Todd Vento discussed telehealth, the concept of “tele-presence” (“the view of you”) and “tele-etiquette”.
Can telehealth improve healthcare disparities? It feels like it has the potential to decrease disparities for geographically isolated, rural communities and other groups (homeless shelters, incarcerated, substance use disorder programs)–but available research actively shows that vulnerable patient populations can be less likely to have telehealth visits, or only have phone instead of video (Kakani 2021, Sachs 2021)–this includes geriatric patients (Nieman 2020, Frydman 2022). Telehealth can be a cost and opportunity savings for patients (ex. Driving cost, time away from work), even those who live across a large metro area let alone across a larger geographic divide (Wienhold 2021, Kamdar 2020 ).
Dr. Leah Marcotte–Primary care models associated with adaptive reserve and psychological safety had lower rates of burnout (Edwards 2021). “The practice adaptive reserve (PAR) scale is a commonly used assessment that quantifies successful work relationships that lead to flexibility and resilience within a practice. (Miller 2010)”
Adipose tissue is an endocrine organ that “defends it’s mass”. Bariatric surgery is a metabolic surgery that can “change the hormonal millieu and lower the body weight set point”. Newer medications for obesity seek these same goals (Dr. Caroline Apovian @marsapovian in the Dr. Ananda Prasad Lecture at ACP 2022).
Tirzepatide is a combined GIP/GLP1 agonist showing promise for both diabetes and weight loss (SURPASS trials 1-5 summarized here by Healio).
Cabotegravir (CAB)+ rilpivirine (RPV) is a long‐acting intramuscular injection with approved dosing every 8 weeks for HIV treatment (Overton 2021).
Cabotegravir long-acting (CAB-LA) IM injection given as PrEP every 8 weeks is superior to oral tenofovir-emtracitabine for HIV prevention (Landovitz 2021). Note: Must test for HIV before each injection to avoid viral resistance.
Don’t forget to screen and treat young folks for HIV in primary care!
Hemoglobin A1C may be less reliable for diagnosis of diabetes in folks with HIV taking ART. An oral glucose tolerance test should be considered to improve detection of new diabetes (Coelho 2018)
Early intervention in Afib, whether with early rhythm control (EAST-AFNET) or an intra-cardiac device/surgery should be considered –Left atrial appendage closure device (Osmancik 2022) –Left atrial appendage occlusion “sew it up” (Whitlock, NEJM 2021).
Patients with heart failure are more likely to benefit from rhythm control (see CASTLE-AF and prespecified follow up to CABANA —Packer 2021)
Listeners will be served delicious knowledge food from ACP’s #IM2022
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Taranto N, Heublein M, Dow A, O’Glasser AY, Chiu CJ, Williams PN, Watto MF. “#333 Prescribing pearls, Periop Medicine, PMR, Gout, OSA, Nocturia, Food as Medicine, a new Obesity paradigm, and rethinking afib! ACP #IM2022 Highlights”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date: May 6, 2022.