Celebrate the holiday season with top pearls on constipation, palpitations, hypertension, meds for obesity, cardiorenal syndrome, hepatitis C, staging the liver, vitamin supplementation and more! Plus, Watto and Paul share their reflections on seven years of podcasting, give their picks of the year, and tease upcoming episodes for 2023!
Featuring Xiao Jing Iris Wang and production and graphics by Elena Gibson
Straining, incomplete evacuation, and manual disimpaction are signs/symptoms associated with rectal evacuation disorders. Ask the patient to try a squatty potty and refer them for pelvic floor physical therapy.
A laxative trial or two kiwis/day (without the skin) is a good first step once you’ve ruled out secondary causes (obstruction, neuropathy, myopathy, metabolic conditions)
Red flags: unintentional weight loss >10% of body weight, anemia, rectal bleeding, a family history of colorectal cancer, and polyposis syndromes
Featuring Josh Cooper and production and graphics by Edison Jyang and Paul Williams
The frequency and severity of symptoms determine which heart monitor to use and whether or not an echo is needed. For instance, a 24-48 hour monitor suffices for daily symptoms, but a two-week monitor is warranted for weekly symptoms and so forth.
PVCs that comprise ≥ 10% of a patient’s beats or in patients with past ischemic/structural heart disease should be further investigated/managed.
Dr. Cooper appreciates when patients bring in rhythm strips or ECGs from a smart device.
In general, the patient with PVCs or supraventricular tachycardia can choose a) to do nothing, b) trial medication like a beta-blocker, or c) go for an EP study +/- ablation.
Featuring Jordy Cohen and production and graphics by Malini Gandhi
Don’t adjust medication based on a “casual office BP.” Obtain additional data from home monitoring or high-quality office readings.
Most patients will need two medications to control their BP. Consider starting a low dose combination, especially if more than 20/10 mmHg above target.
Start with ARBs because they have a better safety profile than ACE inhibitors and are now affordable.
Losartan is short acting, so twice daily dosing might be necessary.
Patients with CKD 4 can be prescribed ACE inhibitors/ARBs and/or diuretics with close monitoring of their renal function (up to 30% increase on an ACEi/ARB) and potassium (keep it under 5.5).
Salt-sensitive hypertension is likely if renin is suppressed even when aldosterone is not elevated. Thus, target renin suppression (ex: MRA or amiloride). Amiloride is an excellent treatment option for this population.
Featuring George Saffouri and production and graphics by Beth Garbitelli and pitched by a listener, Ana Maria Keilhauer Varona
Before testing, patients should be off of proton pump inhibitors (Crowe 2019), antibiotics, and probably H2 receptor antagonists for a month (per Dr Saffouri’s practice, the guidelines indicate 1-2 weeks off PPI and 4 weeks off antibiotics, Chey 2017).
Dr. Saffouri often uses bismuth-based quadruple therapy (bismuth + PPI + tetracycline + metronidazole) as first-line and levofloxacin-based regimens as 2nd line (Huang 2017, Chey 2017) because resistance is high to clarithromycin based triple therapy.
At ACP #IM2022, Dr. Brooks Cash discussed rifabutin-containing therapy (rifabutin + omeprazole + amoxicillin, Graham, 2022), vonoprazan-containing therapy (vonoprazan + amoxicillin +/- clarithromycin), or reverse hybrid therapy (PPI + amoxicillin for 14 days with the addition of clarithromycin and metronidazole for the final seven days) as emerging winners (Rokkas, 2021) due to increasing resistance to clarithromycin, metronidazole, and fluoroquinolones.
Featuring Fatima Cody Stanford and production and graphics by Isabel Valdez, Madison McLellan
Obesity is a chronic disease and requires chronic treatment.
Consider Dr. Cody Stanford’s analogy about weight loss and snow removal: Diet and exercise are like using a spoon to remove snow, medications are like using a shovel, and metabolic surgery is like using a snow plow.
In this episode, we focused on phentermine, topiramate, bupropion, and naltrexone used alone or in combination (since generics are available) to treat obesity. Metformin is another low-cost option that anecdotally helps some of Dr. Cody Stanford’s patients.
The newer GLP1 agonists are available on some state Medicaid formularies but may be limited to patients with diabetes.
We all know to be mindful of hypertension and heart rate when prescribing phentermine, but it’s worth noting that bupropion is more likely to elevate blood pressure than phentermine. Whichever one you pick, keep your eyes on the vitals.
Featuring Joel Topf and Sadiya Khan and production and graphics by Malini Gandhi
Elevated venous pressure and venous congestion, rather than reduced cardiac index with poor forward flow, are thought to be the major contributors to the pathophysiology of cardiorenal syndrome.
Home ACE-is/ARBs and SGLT-2 inhibitors do not necessarily need to be stopped in patients with acute decompensated heart failure with increased creatinine as long as the patient is not hypotensive or hyperkalemic. If these medications are stopped during hospitalization, be sure to restart them before discharge.
A creatinine “bump” with diuresis does not necessarily signify kidney injury. Allow “permissive hypercreatinemia.” Avoid stopping diuresis prematurely with residual congestion on board simply because of increased creatinine.
Sequential nephron blockade might include thiazide/thiazide-like diuretics, mineralocorticoid-receptor antagonists, acetazolamide, or SGLT2 inhibitors.
Hyperdiuresis with hypertonic saline is a terrifying final option for patients refractory to diuretics. This strategy might turn off RAAS signaling and pull in water from the interstitium (NephMadness blog post).
Featuring Christian Ramers, production by Emi Okamoto, and graphics by Lyan Chang
We screen all patients older than 18 years old for Hep C because up to 45% of persons infected with HCV do not recall or report the classic risk factors (Kim, 2019).
Order Hepatitis C antibody with reflex PCR to avoid a loss to follow-up.
Antibody testing may remain positive for life, though up to 46% of HCV-infected persons will spontaneously clear the infection (Seo, 2020), meaning they will have 0 RNA copies.
Initial testing after a diagnosis of Hep C includes serology for HIV and hepatitis B, platelet count, complete metabolic panel, and INR. Consider an abdominal ultrasound of the liver. Genotype testing is no longer routine.
Be sure to “stage the liver” with a fibrosis assessment. The FIB-4 (calculator) and APRI (calculator) scores are good at identifying low-risk or high-risk of cirrhosis, but intermediate cases may require elastography. Proprietary serologic tests for fibrosis also may be used. Liver biopsy is less common these days.
Both first-line drug combinations (g/p and sof/vel) are pangenotypic and have a cure rate of >95%: everyone who can be treated should be treated. Few exceptions exist (e.g. life expectancy <6 months) (AASLD/IDSA simplified treatment, without cirrhosis).
Refer to ID or hepatology if a patient has previously been treated for hepatitis C, has cirrhosis, has HIV or hepatitis B, is pregnant, has hepatocellular carcinoma, or has received a liver transplant.
Offer hepatitis C treatment even if a patient has active injection drug use. This is an opportunity to integrate addiction medicine and hepatitis C treatment with primary care.
Featuring Dr. Michael Barry, produced by Paul Williams and Elena Gibson, graphics by Elena Gibson
Vitamins don’t seem to be all that helpful, and there are potential harms with vitamin E and beta carotene supplementation. However, you can use these recommendations to discuss other recommended healthy behaviors.