Digest 77: A Packed Edition of antibiotic courses, DVT, GLP-1/GIP maintenance & more!

May 29, 2026 | By Nora Taranto

Welcome Back to The Curbsiders Digest!

In this issue we discuss everything from antibiotic courses to upper-extremity DVT management to GLP-1/GIP maintenance strategies, and much more. Effortlessly absorb important medical news, with our monthly newsletter featuring easily digestible analysis of the latest practice-changing articles, and of course…bad puns. 

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Issue 77

05/29/2026

Appetizers (to whet your appetite) 

Palate Cleanser (aka the melon part of the meal) 

The Main Course

A Digestif or two

Appetizers

Brought to you hot off the stove, from a variety of specialties. Delivered in super tasty, bite-sized morsels.  

Joshua Gilman MD, Laura Glick MD

• Best Practices for Sinusitis Antibiotics. In a retrospective propensity score–matched cohort study of over 520,000 adults published in JAMA, investigators evaluated the risk of treatment failure and adverse events with amoxicillin-clavulanate versus amoxicillin for acute sinusitis in adults aged <65. The primary outcome of treatment failure within 14 days (defined as receipt of a different antibiotic, sinusitis-related emergency room/inpatient encounters, or hospitalization for sinusitis complications) was uncommon overall (3.1%) and did not differ significantly between the amoxicillin-clavulanate and amoxicillin groups (3.0% vs 3.1%; RR 0.96). Adverse events were rare in both groups (~1.3%), but amoxicillin-clavulanate was associated with higher rates of secondary infections (e.g. vulvovaginal candidiasis/yeast infections and Clostridioides difficile). These findings support standard-dose amoxicillin as a preferred first-line antibiotic for most. (LG) 
• Mirtazapine for Methamphetamine Use Disorder. A trial just published in JAMA Psychiatry analyzed the safety and efficacy of mirtazapine for methamphetamine use disorder. In a double-blind randomized clinical trial, 344 adults with moderate to severe methamphetamine use disorder received either mirtazapine 30 mg nightly or placebo for 12 weeks in addition to counseling. Mirtazapine produced a modest but statistically significant reduction in methamphetamine use compared with placebo (~7 fewer vs 5 fewer days of use per month from a baseline of ~22 days/month, mean difference, 2.2 days; 95% CI, −4.2 to −0.2 days; P = .02). There were no significant differences between the groups in methamphetamine-negative saliva test results, depression, insomnia, HIV risk behaviors, or quality of life. Adverse effects including sedation, weight gain, and treatment discontinuation were more common with mirtazapine. (LG) 
• How useful is switching direct oral anticoagulants (DOACs) after a breakthrough ischemic stroke in atrial fibrillation (AF)? Breakthrough ischemic strokes remain an issue in patients with AF on anticoagulation, with unclear management strategies. A recent retrospective target trial emulation study published in JAMA Network Open assessed outcomes in 1,006 patients with AFib and a recent breakthrough stroke while receiving DOAC therapy, who either continued their DOAC or switched to another form of anticoagulation (DOAC or vitamin K antagonist). The primary outcome was net clinical benefit at 90 days, defined as the composite of recurrent ischemic stroke and moderate to severe bleeding. The majority of patients were on Apixaban or Rivaroxaban. Of those who switched, the majority were switched to a different DOAC. The primary outcome was similar between switching (4.9%) and continuation groups (5.1%) with an absolute risk difference of 0.3 percentage points ( 90% CI -2.7 to 2.1 percentage points), which met the pre-specified non-inferiority margin of 3%. There was no difference in rates of recurrent stroke, intracranial hemorrhage, or moderate-severe extracranial bleeding. The authors conclude that switching DOAC therapy may not have much meaningful benefit in this scenario. (JG) 
• An ultra-short course of antibiotics for CAP? A recent target trial emulation study published in Annals of Internal Medicine evaluated the efficacy of ultra-short duration antibiotic courses for patients hospitalized with community acquired pneumonia (CAP). This observational study included adults hospitalized with CAP (not in the ICU) without significant pulmonary disease who received either 3-4 days or ≥5 days of antibiotics. Over 55,000 patients hospitalized with CAP were screened; only ~10% met strict eligibility criteria (based on the Pneumonia Short Treatment trial) and of those, only 7.9% (444 patients) actually received 3-4 days of antibiotics. There was no difference in the primary outcome of 30-day all-cause mortality between the groups (0.65% in the short duration group vs 0.73% in the longer-duration group; adjusted risk ratio of 0.89, CI 0.01 to 2.25). There were no differences in rates of readmission, urgent visits, or C. diff infections. (JG) 
• Weight loss maintenance on reduced dose GIP/GLP-1 agonists. The SURMOUNT-MAINTAIN trial, just published in Lancet, evaluated the use of a reduced dose of the GIP/GLP-1 agonist tirzepatide at maintaining weight loss following prior use of a higher, maximally tolerated dose (MTD). 441 patients with obesity were enrolled in a 60-week open-label weight loss period with MTD of tirzepatide (10mg or 15mg). They were then randomized 3:3:2 over a 52-week double-blinded weight maintenance period to one of three options: continuation of MTD, reduced dose (5mg), or placebo. Importantly, patients who did not achieve at least 5% weight loss by the end of the weight-loss period were excluded from the maintenance phase. Rescue tirzepatide was allowed starting at 24 weeks post-randomization (a.k.a. week 84) for patients with > 50% weight regain. Participants in the MTD group experienced a total weight loss of -21.9%, versus -16.6% in the reduced dose and -9.9% in the placebo group (estimated treatment difference compared to placebo of -12% with MTD and -6.6% with reduced dose; p<0.0001). Adverse events, specifically GI-related side effects, were more common in the tirzepatide groups, but only 4% of patients discontinued therapy due to adverse events. (JG) 

Palate Cleanser

Cartoon by Dr. Kate Grant MBChB, MRCGP Study: Lee A, Chen Z, Jossen J … A Prospective Study of Gluten Transfer Through Kissing in Celiac-Discordant Couples. Gastroenterology, 2026; 170, 1600-1605

The Main Course

Alyssa Mancini MD 

Upper extremity deep venous thrombosis: the difference between an arm and a leg?

Upper extremity deep venous thrombosis (UEDVT), defined as a venous thrombosis occurring in the innominate, internal jugular, subclavian, axillary, brachial, ulnar, or radial veins, accounts for 5-10% of all cases of DVT. Until now, management strategies for UEDVT have mainly been based on treatment of lower extremity DVT (LEDVT). However, there are differences in pathologies and etiology, risk of complications (e.g. recurrent thromboembolism, pulmonary embolism, and post-thrombotic syndrome), and significant variations in clinical practice—including inconsistent use of anticoagulation, in part due to lack of clinical guidelines.

Enter the American Venous Forum clinical practice guideline on the care of patients with UEDVT, just published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders. This guideline aims to provide a comprehensive framework for the diagnosis, management, and prevention of UEDVT, with special consideration given to higher risk individuals, such as those with catheter-associated thrombosis, cancer-association thrombosis, and thrombophilia.

How should UEDVT be categorized, and what are the risk factors? (Guideline 1)

·      UEDVT should be categorized by etiology (instead of anatomy) – venous thoracic outlet syndrome (vTOS)-associated UEDVT, catheter-associated UEDVT (CA-UEDVT), and noncatheter-associated UEDVT (NCA-UEDVT).

·      Common risk factors for UEDVT are costoclavicular compression, presence of an intravenous device, active malignancy, and surgery or trauma of the upper extremity.

How should UEDVT be diagnosed, and who should be tested? (Guideline 3)

·      The Constans or Extended Constans score (over the Wells score) should be used to determine the clinical probability of UEDVT and help guide subsequent investigation.

o   The Constans Score awards points for catheters, pacemakers, or other venous material present in the vein (+1), localized pain (+1), unilateral edema (+1), and removes a point for having another diagnosis at least as plausible (-1). 1 point suggests intermediate risk, and 2 or greater suggests high risk.

·      D-dimer testing with a cutoff value of 500 ug/L may be used as an initial test for ruling out NCA-UEDVT in patients with low pretest probability, but should NOT be used to rule out CA-UEDVT. (Guideline 3.4)

·      Upper extremity duplex ultrasound (DUS) is the diagnostic test of choice in patients with clinically suspected UEDVT, with the understanding that it may have low sensitivity and specificity for detecting proximal UEDVT involving central veins. (Guideline 4)

·      If the initial upper extremity DUS is negative but clinical suspicion remains high, magnetic resonance venography (MRV) or computed tomography venography (CTV) should be pursued. (Guideline 4.4)

·      Screening with DUS for CA-UEDVT in patients with long-term indwelling catheters should not be routinely performed in asymptomatic patients. (Guideline 4.3)

What should be done to prevent UEDVT? (Guideline 5)

·      Intermittent mechanical compression devices are not recommended as the sole prophylaxis for prevention of UEDVT. (Guideline 5.1)

·      Routine anticoagulant prophylaxis for prevention of UEDVT is not recommended in patients with long-term central venous catheters. (Guideline 5.4) 

·      Anticoagulant prophylaxis is recommended in those with moderate- to high-risk of venous thromboembolism (after a risk/benefit analysis). (Guideline 5.5)

How should UEDVT be treated?

· UEDVT should be treated with oral Xa inhibitors over vitamin K antagonists for at least 3 months in patients with low bleeding risk. (Guideline 6.1)

· CA-UEDVT should be treated with anticoagulation and catheter removal (if the indwelling catheter is no longer necessary or alternative access is feasible), and anticoagulation should continue for the duration the catheter is in place and extend for 3 months after its removal. (Guideline 6.5)

· NCA-UEDVT should also be treated with anticoagulation for >3 months in patients with low bleeding risk (Guideline 6.6). Invasive interventions for NCA-UEDVT can be considered if the patient is highly symptomatic, has low surgical risk, and has a life expectancy > 1 year. (Guideline 6.7)

·      In highly selected individuals with an absolute contraindication to anticoagulation and elevated risk of life-threatening pulmonary embolism, temporary superior vena cava filter placement should be considered. (Guideline 6.8)

·      In patients with a first, unprovoked episode of UEDVT, underlying causes such as malignancy and hypercoagulability disorders should be investigated. (Guideline 6.2)

Read the full article HERE!

Digestifs

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This week on The Curbsiders: Check out the latest DIGEST Episode #526, to hear us dive into the latest in pancreatic cancer game changing treatment, lipid guideline updates, and GLP-1/GIP endoscopy holds. 

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The Curbsiders Digest

Issue 77
Editor in Chief: Nora Taranto MD
Banner: Kate Grant  MBChB, DipGUMed

Kate Grant, Joshua Gilman, Laura Glick, Alyssa Mancini, and Nora Taranto report no disclosures.

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