In this post, I link to and excerpt from The Curbsiders’ outstanding #333 Prescribing pearls, Periop Medicine, PMR, Gout, OSA, Nocturia, Food as Medicine, a new Obesity paradigm, and rethinking Afib! ACP #IM2022 Highlights.*
*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. https://thecurbsiders.com/episode-list Final publishing date: May 6, 2022.
All that follows is from the above resource.
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!
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).
Common drug interactions and side effects
- 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)
- Check out our tramadol discussion with David Juurlink: https://thecurbsiders.com/podcast/146-nephmadness-pain-meds-in-chronic-kidney-disease)
- 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)