Don’t miss this rapid-fire recap of our top pearls from #SGIM23 in Aurora, Colorado, including obesity medicine, GLP1 agonists, trauma-informed care, an update on hormone therapy for vasomotor symptoms of menopause, treating low sexual desire in women, dementia diagnosis and treatment, chronic pain and buprenorphine, complex persistent opioid dependence, chlorthalidone vs hydrochlorothiazide, the timing of blood pressure medication, how to prescribe CPAP or auto-PAP, and more! Paul and Watto are joined by Drs. Justin Berk (@justinberk), Chris Chiu (@cjchiu), Carolyn Chan (@CarolynAChanMD, Curbsiders Addiction Medicine), and Era Kryzhanovskaya (@EraKryzhMD, Curbsiders TEACH).
Buprenorphine therapy is a possible option for patients with CPOD (expert opinion).
Sublingual buprenorphine formulations have higher doses and may be appropriate for patients on over 60 to 90 mg morphine equivalents (MME) per day and lower dose transdermal or buccal formulations may be appropriate for patients receiving under 60 MME per day (expert opinion).
Effect of Basic Income on Health Care Utilization:
Evidence from a Randomized Study of Cash Benefits by Dr. Sumit Agarwal
Families were selected via lottery, living in Chelsea, Massachusetts (outside Boston) to receive a $400 monthly cash benefit for 10 months. Participants were free to spend money however they chose. The primary outcome was ER visits. They observed a significant decrease in ED visits by one-third in the cash benefit group!
Clinical Updates in Cardiovascular Risk Factors
Presenters: Drs. Jennifer Cluett, Kelsey Bryant, Allison Crawford, Benjamin Gallagher, Eva Tseng
Switching patients from hydrochlorothiazide to chlorthalidone did not reduce major adverse cardiovascular events in a group of patients with a mean systolic blood pressure of 139 mmHg (Ishani, 2023).
Dosing blood pressure medication at bedtime did not improve major adverse cardiac events (Mackenzie, 2022).
Case of syphilis
The Great Imitator Strikes Again: A Curious Case of Headache by presenter: Dr. Anne Arnason
An individual presented with a headache and MRI demonstrated a right frontal bone lesion with pachymeningeal enhancement and PET uptake. Workup was positive for syphilis. Bony involvement is an unusual manifestation of syphilis (Huang, 2007; Park, 2014) but may be more common in early syphilis than previously thought.
There has been a rise in syphilis across the country. In 2022, the USPSTF recommended screening in persons at high risk for infection (Grade A, USPSTF 2022). An optimal screening interval has not been defined but should be at least annually in high-risk persons (maybe even every 3 to 6 months (USPSTF 2022).
Demystifying Obesity Medicine for Primary Care workshop with Drs. Noor Khan, Lakshmi Niranjan, Mihir Patel, Mehrshid Kiazand, Amy Sheer
Use the FITTE mnemonic for exercise prescription: Frequency (e.g. 5x days), Intensity (e.g. moderate), Time (e.g. 30 minutes during lunch hour), Type (e.g. walking), E (Enjoyment) –expert opinion.
Antipsychotic medications promote weight gain, so consider adding metformin, a GLP-1 agonist, or phentermine/topiramate to counteract this weight gain (Marteene, 2019; Generali, 2014)
Some patients lose significant weight with metformin (based on expert’s experience) and insurance companies may require a trial of metformin before a GLP1 agonist will be approved.
Phentermine/topiramate lowered blood pressure (probably due to weight loss), but caused a small increase in heart rate that was dose-dependent (Gadde, 2011). The speakers again mentioned bupropion commonly elevates blood pressure and heart rate (Alfaris, 2020).
Taking more daily steps significantly lowers all-cause mortality by 40-53% when comparing the lowest quartiles with the higher quartiles (Paluch, 2022)! There was a dose-dependent response up to a point of 6,000-8,000 if older than 60 and 8,000-10,000 if under 60.
Tri-agonists with GLP1/GIP/glucagon are in development. GLP1/GIP agonists have anorectic and insulinotropic effects while glucagon increases energy expenditure (Knerr, 2022).
Hormone Therapy for Menopause
Hormone Therapy (HT) is the most effective treatment for vasomotor symptoms of menopause (VMS). Consider HT if at least moderate VMS (NAMS 2022).
Use the minimum effective dose. Non-oral routes are preferred due to better risk profile (NAMS 2022).
The experts recommended an attempt to wean after about 5 years, but the decision to continue should be based on symptoms, comorbidities, and long-term risk of VTE, cardiovascular events, and cancer (NAMS 2022).
The HT risk profile is most favorable for women under 60 yo or less than 10 years from menopause (NAMS 2022).
Personal and familial risks of CVD, stroke, VTE, and breast cancer should be considered when initiating hormone therapy (NAMS 2022).
Presenters shared this algorithm to assess cardiovascular (CV) risk of HT 1) Assess for existing cardiovascular disease and avoid HT if present. 2) Identify existing CV risk factors and calculate ASCVD risk score. Avoid HT if high ASCVD risk score or a coronary artery calcium score (CAC) above 100. Use shared decision-making if intermediate CV risk. HT is probably safe if low CV risk.
Presenters shared this algorithm to assess breast cancer risk of HT 1) assess for a personal or strong family history of breast or ovarian cancer, or chest radiation before 30 years old. Avoid HT if present. 2) Calculate a Gail score. Avoid HT if high risk by Gail. Use shared decision-making if intermediate risk. The absence of a uterus would favor treatment if intermediate risk. Recommend HT if low Gail risk score.
Low Sexual Desire in Women
Making Sparks Fly – Low Sexual Desire in Women. Screening, Therapy by presenters Hannah Abumusa, Leah Koenig, Talia Sobel, Brielle Spataro, Holly Thomas
Per the speakers, nearly half (43%) of women in the US report living with sexual concerns. Low sexual desire (aka hypoactive sexual desire disorder) affects 38% of women with a significant negative impact on women across the lifespan.
The decreased sexual desire screener (DSDS) can be used to diagnose low sexual desire (Clayton, 2009).
Non-pharmacologic treatments for low sexual desire include mindfulness-based interventions. Also, look to deprescribe meds that might be causing low sexual desire (e.g. SSRI) before prescribing a new medication –expert opinion.
Two medications are FDA-approved in premenopausal women to treat low sexual desire. Flibanserin, a once-daily pill taken in the evening, received controversial approval (Baid, 2018) and has potential side effects of CNS depression and hypotension/syncope. Bremelanotide is an injection given 45 minutes before sexual activity that activates melanocortin receptors, but works by an unknown mechanism (FDA.gov site accessed 18 May 2022).
Bupropion, buspirone, and testosterone are also used to treat sexual dysfunction in women (UpToDate “Sexual Dysfunction in Females” accessed 18 May 2023).
Obstructive Sleep Apnea
Is OSA Keeping You Up at Night? Learn to Manage Obstructive Sleep Apnea Like an Expert? Jessica Camacho, MD; Katherine Green, MD, MS; Mindy Busby, PA; Ann Cartwright, PA; Gruber Curtis, RT
A reasonable goal for PAP therapy is an Apnea Hypopnea Index (AHI) under five events per hour (expert opinion).
It’s reasonable to start auto-titrating positive airway pressure (PAP) at 5 to 15 cmH20. Check the devices 30-day summary report to review the AHI and median PAP to determine if pressure adjustments are needed –expert opinion.
Use these scripts to SET expectations. “I expect that you will NOT like it at the beginning.” “Our long-term goal is to use it every night.” “It will take time to get acclimated…4-6 weeks or longer.” –expert opinion.
Try graded exposure. Before wearing PAP during sleep, try wearing PAP while awake as “practice” (e.g. Patients can watch TV, or use their phone) –expert opinion.
Try out different PAP attachments (e.g.nasal prongs, full face mask, nasal only mask, mouth only mask) and hose placements (e.g. can place hose on top of head or nose). Experts recommended patients take advantage of the 30-day trial window to return attachments if they don’t like them. Many companies will replace attachments every three months due to normal wear and tear –expert opinion.
Surgeries of the palate or tongue (volume reduction) are available for those intolerant of PAP therapy (Gottlieb, 2020), but the speaker estimaged a general success rate of about 30 percent for most procedures.
A hypoglossal nerve stimulator (similar to a pacemaker) is available. It causes the tongue to move forward at the appropriate time. Recovery is quick and easy versus other surgeries. This is NOT better than PAP and should only be offered if intolerant of PAP –expert opinion.
Clinical Updates in Dementia Care and Prevention: Drs. Halima Amjad, Stephanie Nothelle, Mary Thomas, Mia Yang
Dementia Prevention: there are 12 modifiable risk factors that account for forty percent of dementia (Livingston, 2020).
Mitigate cognitive decline by treating hearing loss (Yeo, 2022) and vision loss with cataract surgery (Lee, 2021).
Tight control of blood pressure did not prevent cognitive decline in a meta-analysis (Dallaire-Théroux, 2021). The earlier SPRINT MIND trial found a reduction in mild cognitive impairment, but not dementia (Williams, 2019).
Treat depression in dementia with cognitive stimulation, exercise/social interaction, massage/touch, and reminiscence therapy (Watt, 2021).
Lecanemab for early Alzheimer’s dementia (AD) reduced markers of amyloid and resulted in moderately less decline on measures of cognition and function than placebo at 18 months but was associated with adverse events (Van Dyck,2023)
Donanemab is a new AD med in clinical trials with early reports of improvement in activities of daily living, but data is yet to be release from the latest TRAILBLAZER-ALZ trial.
Normal aging includes misplacing keys or trouble recalling a name. Worrisome signs include 1) forgetting what just happened 2) difficulty with complex tasks (e.g. holiday recipe), or 3) becoming unaware in a familiar place –(cognition-primarycare.org accessed 18 May 2023).
The speakers recommended allowing a full appointment for cognitive testing and another full appointment for counseling if dementia or mild cognitive impairment is confirmed. Time-based coding will allow billing for a 99215 visit –expert opinion.
Our own Dr. Chiu performs a mini-cog first. If abnormal, then he gives the patient a SAGE exam handout to take home and complete. SAGE was developed at THE Ohio State University.
Clinical Updates in Primary Care
Drs. Jason Alexander, Amy Chen, Amber Pincavage, Sachin Shah, Simran Singh, Jerem Smith, David Williams
NOSTONE Trial (Dhayat, 2023): Hydrochlorothiazide did not reduce recurrent kidney stones.
CORDIOPrev randomized controlled trial (Delgado Lista, 2022): Mediterranean diet was associated with a significant reduction in major adverse cardiac events for secondary prevention when compared to a low fat diet over 7 years of follow up.
We do not need to stop RAS inhibitors in patients with advanced kidney disease. STOP-ACE Trial (Bhandari, 2022).
Albuterol-budesonide can decrease emergency/hospital visits and steroid use when compared to albuterol alone in patients already prescribed a controller inhaled corticosteroid. This combination will not be available in the US for another year or two (Papi, 2022).
Links are embedded in the show notes above.
Listeners will recap the top pearls from #SGIM23
After listening to this episode listeners will…
Feel generally warm and happy inside
Feel like they attended #SGIM23
Fall deeper in love with Dr. Paul Nelson Williams, #americasPCP
The Curbsiders and The Cribsiders report no relevant financial disclosures.
Watto MF, Williams PN, Chiu CJ, Berk JL, Chan C, Kryzhanovskaya E. “#396 Recap, Top Pearls from #SGIM23”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date May 22, 2023.
Written, Produced, and Hosted by: Justin Berk MD, MBA, MPH; Chris Chiu MD, FACP, FAAP; Carolyn Chan MD; Era Kryzhanovskaya MD; Matthew Watto MD, FACP; Paul Williams MD, FACP Show Notes: Matthew Watto MD, FACP Cover Art: Matthew Watto MD, FACP Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP Technical Production: PodPaste