Episode 231 -- June 2025 -- Part 1 AFP: American Family Physician

Summary

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AFP: American Family Physician Podcast

Episode 231 – June 2025 – Part 1
University of Arizona College of Medicine–Phoenix Family Medicine Residency
Date: June 16, 2025
Contributing Editor: Dr. Steven Brown

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Overview

In this episode, the AFP Podcast team of faculty and residents reviews clinical highlights from the June 2025 issue of American Family Physician. They cover key topics relevant to primary care: acute monoarthritis in adults, strategies to improve adverse drug reaction (ADR) reporting, the appropriate use of oral antiplatelet drugs, best practices for long-term opioid therapy, an evidence update on treating Clostridioides difficile (C. diff) infection, and a review of lecanemab for Alzheimer’s disease. The tone is practical and collegial, and the hosts frequently underscore the real-world implications for family medicine.

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Acute Monoarthritis Diagnosis in Adults

(00:30–06:31)

Key Points:

• Etiologies:

  • Common: Osteoarthritis, gout, pseudogout, trauma
  • Less common: Septic arthritis, Lyme arthritis, pigmented villonodular synovitis

• Clinical Pearls:

  • Osteoarthritis: Seen in older adults, presents with limited ROM, effusion, and activity-induced pain relieved by rest.
  • Gout: “Most common crystalline arthropathy” (02:22, C. Alvarez), typically in the first MTP joint; treat with uric acid lowering agents if tophi are present.
  • Pseudogout: Caused by calcium pyrophosphate crystals, presents similarly but differentiated by crystal analysis.

• Septic Arthritis:

  • “If fevers are present in monoarthritic patients, septic arthritis should be considered until ruled otherwise.” (02:56, C. Alvarez)
  • Higher risk with prosthetic joints. Staphylococcus is most common.

• Lyme Arthritis:

  • Consider in endemic areas, especially in younger patients with outdoor exposure.

• Pigmented Villonodular Synovitis:

  • “Tumor which commonly affects knees, hips, and ankle joints with recurrent hemarthrosis.” (03:40, V. Vasquez)

• Diagnostic Approach:

  • First, check for effusion and diminished/passive ROM. Periarticular pathology (e.g., bursitis) preserves ROM. (04:03, S. Brown)
  • Imaging: Use US/MRI if joint effusion is unclear; X-ray features for OA: joint space narrowing, osteophytes, subchondral sclerosis.
  • Joint aspiration & fluid studies:
    • WBC <2,000: Non-inflammatory
    • WBC >50,000 & neutrophils >90%: Suggests septic arthritis
    • “If WBCs are 100,000 or greater, the positive likelihood ratio rises to 13.2.” (05:15, S. Brown)

• Special Tests:

  • Crystal analysis: “Gout demonstrates negative birefringence while pseudogout demonstrates positive... P and pseudogout begins with P positive.” (06:00, C. Alvarez)
  • Lyme: PCR is the most accurate, with 100% specificity.

Memorable Quote:

• “Septic arthritis should be considered until ruled otherwise.” (02:56, C. Alvarez)

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Improving Adverse Drug Reaction Reporting

(06:31–09:36)

Key Points:

• Educational Interventions:

  • Education combined with practical tools (e.g., reporting forms/reminder cards) triples ADR reporting rates (risk ratio ≈3), albeit from low baseline. (06:59, C. Alvarez)
  • “You can’t just do like a lecture or put a flyer in the break room... those have no meaningful effect.” (07:37, S. Brown)

• System-Level Solutions:

  • Embedding ADR reporting prompts into hospital discharge forms doubled reporting. (07:55, V. Vasquez)
  • “Just adding a checkbox or prompt during discharge can remove the friction.” (08:10, S. Brown)

• Barriers:

  • Lack of awareness, unclear roles, time constraints, incomplete information, and diffusion of responsibility.
  • Pharmacists are more knowledgeable about ADR reporting compared to physicians and nurses.

• Call to Action:

  • “If you’re in a hospital or clinical setting, start by asking: do our staff know how to report an ADR?” (09:36, V. Vasquez)

Notable Statistic:

• “Up to 94% of ADRs go unreported. That's staggering and dangerous.” (09:18, S. Brown)

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Inappropriate Use of Oral Antiplatelet Drugs

(09:56–12:10)

Key Points:

• Guideline Highlights:

  • Aspirin for primary prevention:
    • Ages 40–59 with elevated risk: “C” recommendation (shared decision).
    • Age ≥60: “D” (don’t do). (10:29, S. Brown)
  • Always balance CV benefits against bleeding risks.

• Risks:

  • “Factors include advanced age, recent falls, history of bleeding, chronic anemia, CKD, and female sex.” (10:56, V. Vasquez)

• Specific Cautions:

  • Stop antiplatelet drugs 5–7 days before surgery.
  • Dual antiplatelet therapy (DAPT) is only recommended short-term for indicated patients, not long-term.
  • “Adding aspirin to warfarin is surprisingly common and should be used with caution.” (11:26, S. Brown)
  • Inappropriate combinations (e.g., aspirin + DOAC) should be discouraged unless clear indication.

• Clinical Takeaway:

  • “Maybe you can stop some of these meds in some of your patients, especially older ones with more bleeding risk.” (12:05, C. Alvarez)
  • “Be a med stopper. Deprescribing for the win.” (12:10, S. Brown)

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Long-Term Opioid Therapy for Non-Terminal Pain

(12:44–16:56)

Key Points:

• Current Trends:

  • Opioid prescribing has halved in the last decade, but still, 22% of adults with chronic pain used opioids in the past 3 months.

• Equity Concerns:

  • Racial/ethnic minorities, women, older adults, transgender people, and those with cognitive/mental illness get less adequate pain treatment, and are likelier to have opioids abruptly stopped. (13:21, V. Vasquez; 13:37, S. Brown)
  • “It’s not just poor access, it’s active bias.” (13:37, S. Brown)

• Treatment Role:

  • Opioids should be last-resort for chronic, non-terminal pain.
  • “They’re not better than NSAIDs, antidepressants, or anticonvulsants... studies rarely go beyond 6 months.” (14:12, S. Brown)

• Risks:

  • Constipation, depression, hormonal suppression, sexual dysfunction, infertility, opioid-induced hyperalgesia, withdrawal, misuse, and overdose.

• Risk Mitigation & Tools:

  • Use assessment tools such as DIRE (Diagnosis, Intractability, Risk, Efficacy).
  • Calculate morphine milligram equivalents (MME).
  • Screen for co-prescribed benzos, psych issues.

• Safe Prescribing:

  • Set “realistic goals—not necessarily pain-free, but maybe able to walk a block or sleep through the night.” (15:15, C. Alvarez)
  • Favor immediate-release opioids, not extended-release.
  • Check state PDMPs, use PHQ2, GAD2 for screening.
  • Don’t abruptly discontinue—taper slowly (“Think months to years, not weeks.” – 16:33, S. Brown).

• Buprenorphine:

  • Partial agonist, lower overdose risk. Ideal for OUD or high misuse risk, and for persistent dependence after opioid tapering, even without OUD diagnosis.
  • “Transdermal for lower-dose, sublingual for higher-dose, but careful induction required.” (16:06–16:19)

• Best Practices:

  • Combine medical and psychological support (CBT, PT, mindfulness).
  • “Shared decision-making every step of the way.” (16:56, V. Vasquez)

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Medicine by the Numbers: Fidaxomycin vs. Vancomycin for C. Diff

(17:11–19:03)

Key Points:

• Evidence:

  • IDSA guidelines now recommend fidaxomycin as first-line for both initial and recurrent C. diff cases.
  • Meta-analysis shows “number needed to treat (NNT) of 16” for resolution without recurrence or death vs. vancomycin (18:05, S. Brown).
  • In mild/moderate C. diff, fidaxomycin is superior; in severe cases, equal efficacy.
  • Limitation: Lacks long-term safety data/adverse events reporting.

• Access/Cost:

  • Fidaxomycin: ~$5,100 per course vs. ~$40 for vancomycin. (18:40, C. Alvarez)
  • Availability and insurance coverage are barriers.

• Takeaway:

  • “Benefits outweigh harms” with fidaxomycin for C. diff, when accessible.

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STEPS Drug Review: Lecanemab for Alzheimer’s Disease

(19:03–21:57)

Key Points:

• Indication:

  • For adults with early Alzheimer’s (mild cognitive impairment or mild dementia, MMSE 20–28) and confirmed amyloid pathology.

• Safety:

  • Amyloid-related imaging abnormalities (ARIA) in up to 20% (number needed to harm: 36).
  • ARIA can cause headache, confusion, tremor, gait changes. Intracerebral hemorrhage <1%.
  • APOE4 status may help risk stratify but isn’t widely tested.

• Tolerability:

  • 20% have infusion reactions, mostly mild/moderate. 7% stopped drug (vs. 3% placebo, NNH 25).

• Effectiveness:

  • Two studies: No clinically meaningful cognitive benefit in one; minimal effect (0.45 out of 18 points prevented worsening) in larger trial.

• Price/Simplicity:

  • $27,000 per year (excludes MRI or clinical management). (21:21, V. Vasquez)
  • Infused every two weeks; MRIs at baseline and before key infusions.

• Clinical Bottom Line:

  • “This drug is expensive with noteworthy risks.” (21:48, S. Brown)
  • “Patients need to have early disease and confirmed amyloid plaques.” (21:53, V. Vasquez)
  • Shared decision-making vital.

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Notable Quotes & Memorable Moments

• On bias in opioid prescribing:
  “It’s not just poor access, it’s active bias.” (13:37, S. Brown)

• On underreporting of ADRs:
  “Up to 94% of ADRs go unreported. That's staggering and dangerous.” (09:18, S. Brown)

• On deprescribing:
  “Be a med stopper. Deprescribing for the win.” (12:10, S. Brown)

• On evidence vs. experience:
  “Patients are often perceiving benefits beyond the data... We need to acknowledge their lived experience even as we stay grounded in evidence.” (14:23, C. Alvarez)

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Timestamps for Segments

• Acute Monoarthritis: 00:30–06:31
• Adverse Drug Reaction Reporting: 06:31–09:36
• Oral Antiplatelet Drugs: 09:56–12:10
• Long-Term Opioid Therapy: 12:44–16:56
• C. Diff Treatment Update: 17:11–19:03
• Lecanemab for Alzheimer’s Disease: 19:03–21:57

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Summary

This episode delivers evidence-based, practical updates for family physicians on timely and sometimes controversial topics. The panel emphasizes clinical reasoning, equity, and patient-centered care, particularly in nuanced areas like opioid management and preventive pharmacology. Key reminders include the need for rigor in ADR reporting, critical appraisal of high-cost new drugs, and a readiness to stop or adjust therapies where harms outweigh benefits.

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Transcript

[Podcast Host/Announcer]

The AFP Podcast is brought to you by the American Academy of Family Physicians and by Aledade, the largest network of independent primary care. Alidade provides actionable insights and workflow support for clinicians to keep their patients healthy while generating more revenue through value based care. Learn more about ACO partnership [e-mail] welcome.

[Steve Brown]

To the American Family Physician podcast for part one of the June 2025 issue. I'm Steve.

[Christopher Alvarez]

I'm Christopher.

[Valeria Vasquez]

I'm Valeria.

[Steve Brown]

We are residents and faculty, mostly residents from the University of Arizona College of Medicine, Phoenix Family Medicine Residency. Today on the podcast we're going to talk about acute monoarthritis, improving adverse drug reaction, reporting inappropriate use of oral antiplatelet drugs, long term opioid therapy treating C. Diff infection, and lecanemab for Alzheimer's disease.

[Podcast Producer/Additional Staff]

The opinions expressed in the podcast are our own and do not represent the opinions of the American Academy of Family Physicians. The editor of American Family Physician or Banner Health. Do not use this podcast for medical advice. Instead, see your own family doctor for medical care.

[Additional Staff/Guest]

We're on a mission. Delivering the best from American Family Position on a nation Delivering the Best from American Family Physician.

[Steve Brown]

Okay, we're going to start with acute monoarthritis diagnosis in adults from Dr. Swisher, Sitten, Burbank and Nelson.

[Christopher Alvarez]

Shout out to Dr. Swisher from UCLA. I rotated with him. He's a great fellow.

[Steve Brown]

Nice.

[Valeria Vasquez]

All right, let's talk about monoarthritis, a single joint pain and swelling.

[Christopher Alvarez]

The most common etiologies for acute monoarthritis include osteoarthritis, gout, pseudo gout and trauma. Other conditions include septic arthritis, lyme arthritis and pigmented velo nodular synovitis.

[Steve Brown]

Okay, first we're going to talk about osteoarthritis. Osteoarthritis is a degenerative condition affecting older adults. Joints affected by osteoarthritis commonly present with limited range of motion, effusion, morning stiffness and activity induced pain relieved with rest.

[Christopher Alvarez]

Yeah. The second most common is probably gout, and this is the most common crystalline arthropathy with monosodium urate crystals affecting the joints, and it's predominantly in the first MTP joint. These joints present with tophiz formation, swelling, warmth and maximal pain within 24 hours of onset. If TOPHI are present, patients should be treated with uric acid lowering agents with a goal of less than 6 of serum uric acid.

[Valeria Vasquez]

Next, pseudogout. Pseudogout is another crystalline arthropathy in this Case caused by calcium pyrophosphate crystals.

[Christopher Alvarez]

Now on to the less common etiologies. So beginning with septic arthritis, it's an urgent condition where patients, in addition to pain and swelling, may also have fever rigors and diaphoresis. If fevers are present in monoarthritic patients, septic arthritis should be considered until ruled otherwise. Suspicion should also be higher in patients if they have a prosthetic joint. Staphylococcus is the most common pathogen of septic arthritis. Something to keep in mind.

[Steve Brown]

Next, if you live in the northeast or upper Midwest, you are likely familiar with Lyme. Lyme arthritis tends to affect younger patients in endemic areas, is caused by Borrelia burgdorferi by tick transmission in outdoor exposure.

[Valeria Vasquez]

Oh, and another important monoarthritis is pigmented velo. Nodular synovitis is it's less common but insidious. This is a tumor which commonly affects knees, hips and ankle joints with recurrent hemarthrosis and joint destruction affecting typically women between 20 to 40 years of age.

[Steve Brown]

Okay, so now we know the culprits. How do we approach the diagnosis? When examining these patients with monoarthritis, you should first determine if the affected joint has an effusion which can signify intra articular pathology. Affected joints have diminished and painful passive range of motion. This is highly suggestive that the underlying diagnosis affects the joint itself. Periarticular conditions, on the other hand, such as bursitis or tendinitis, present with preserved passive range of motion.

[Christopher Alvarez]

Laboratory testing and imaging can be useful in identifying the correct etiology of acute arthritis. If the examination is unclear for the presence of joint effusions, ultrasonography or MRI could be considered.

[Valeria Vasquez]

And if X rays are obtained, osteoarthritis should be suspected. If hallmark features are present, including joint space narrowing, osteophytes, subchondral sclerosis and cysts.

[Christopher Alvarez]

Joint aspiration and fluid studies can be obtained to narrow down etiologies from inflammatory causes such as crystalline arthropathy and infection. These fluid studies should include a complete blood cell count, gram stain culture and crystal analysis.

[Steve Brown]

All right, you're going to have to pay attention to some numbers here. So white blood cell Counts less than 2,000 strongly suggest a non inflammatory cause of the effusion. WBC counts greater than 50,000 and a neutrophil count of more than 90% suggests septic arthritis. If white blood cells are 100,000 or greater, the positive likelihood ratio rises to 13.2.

[Valeria Vasquez]

For septic arthritis, a synovial fluid neutrophil to lymphocyte ratio of 25 or more, has a sensitivity of 78% and specificity of 81% and is the most suggestive indicator for septic arthritis outside of a positive bacterial culture.

[Christopher Alvarez]

With crystal analysis, gout demonstrates a negative birringence while pseudogout demonstrates a positive birringence. And I remember that by P and pseudogout begins with P positive.

[Steve Brown]

All right. PCR is the most accurate test for lyme arthritis with 100% specificity. And the result comes back faster compared to ELISA and Western blot.

[Christopher Alvarez]

Yeah, there's a great algorithm in the article to help you make the diagnosis for a single painful joint.

[Valeria Vasquez]

American family physician is great with algorithms.

[Steve Brown]

Yep. Next, a Cochrane review. Educational interventions improve adverse drug reaction reporting from Drs. Chang Rhode Sarkar from Baylor in Houston, Texas.

[Valeria Vasquez]

Today we have the clinical question, do educational interventions improve the likelihood that healthcare professionals will report adverse drug reactions or ADRs?

[Steve Brown]

Yeah, we have a systematic review from Cochrane to answer that question.

[Christopher Alvarez]

When education is combined with a tool like adverse drug reaction reporting forms and reminder cards, the reporting rates increase significantly. We're talking about a risk ratio of three, meaning three times more reports compared to standard spontaneous reporting.

[Steve Brown]

So, like it goes from no reports to just slightly more than no reports.

[Valeria Vasquez]

Yes, this is low certainty evidence. Also, most of the studies were conducted at large tertiary centers. Centers in high income countries outside of the U.S. still, it suggests that pairing education with practical tools can drive behavior change.

[Steve Brown]

Yeah, you can't just do like a lecture or put a flyer in the break room. Most studies showed that when educational efforts were isolated, such as just emails, we all want more emails or the always helpful informational letters. Those have no meaningful effect on reporting rates.

[Valeria Vasquez]

There was also an interesting finding around hospital discharge forms. In one study, just having ADR reporting embedded in the discharge process doubled the number of reports submitted.

[Steve Brown]

I know you guys want more to do on the discharges.

[Valeria Vasquez]

Oh, yes.

[Steve Brown]

So that's a pretty simple systemic change. Just adding a checkbox or prompt during discharge. This can remove the friction. And we know that friction is a huge reason that we don't report these things.

[Christopher Alvarez]

Yeah, barriers to ADR reporting are well documented. Lack of awareness, for example, unclear responsibilities, time constraints, and even limited information from patients.

[Valeria Vasquez]

Now who owns this task? Well, often we assume someone else will report it. Yeah, but unless it's built into a process or championed by a team, it falls through the cracks.

[Steve Brown]

One point that really stood out from an additional systematic review. Pharmacists had a significantly higher awareness and understanding of ADR reporting. Systems, unsurprisingly, compared to physicians and nurses.

[Christopher Alvarez]

I think this shows we might need targeted educational efforts specifically for physicians and nurses.

[Valeria Vasquez]

And let's not forget MedWatch. That's the FDA reporting system here in the U.S. it's straightforward. You provide just the drug, name, the event, your name. There's even a training video online. But how many of us have actually used it?

[Steve Brown]

I used it once. Yeah, but that's not very much for how long I've been doing this. So definitely not enough of us do this. Clearly, the data shows that up to 94% of ADRs go unreported. That's staggering and dangerous.

[Christopher Alvarez]

So how should we move forward?

[Valeria Vasquez]

Let's make this practical. If you're in a hospital or clinical setting, start by asking, do our staff know how to report an adr? Do we make it easy for them? And if the answer is no, advocate for change. They add up.

[Steve Brown]

And we can always send more emails.

[Valeria Vasquez]

Love those emails.

[Steve Brown]

Next, we have a Loune right Care Loun is reducing overuse and underuse. Today's topic is inappropriate use of oral antiplatelet drugs. This is from Drs. Roth and Lazarus from New York and Maryland, with patient perspectives from Helen Haskell and John James. Okay, so antiplatelet drugs we're talking about today include aspirin, the oral thiopyridines like clopidogrel and phosphodiesterase 3 inhibitors like cilostazole.

[Valeria Vasquez]

Antiplatelet use has increased in the past two decades.

[Steve Brown]

The use of aspirin for primary prevention is controversial. The USPSTF gives aspirin for primary prevention a C recommendation for those ages 40 to 59 or with elevated cardiovascular risk, and a D recommendation to patients over 60 for primary prevention. So C is a shared decision. D Don't do.

[Christopher Alvarez]

The benefits to prevent cardiovascular events have to be balanced with the harms of major bleeding.

[Valeria Vasquez]

Factors associated with increased bleeding include advanced age, recent falls, history of bleeding, chronic anemia, chronic kidney disease, and female sex.

[Steve Brown]

Make sure to assess bleeding risk for your patient regularly and stop antiplatelet drugs five to seven days before surgical procedures.

[Christopher Alvarez]

Dual antiplatelet therapy, or dapt, is also becoming more common.

[Valeria Vasquez]

DAPT is beneficial short term in specific patients, but it's not recommended long term.

[Steve Brown]

And adding aspirin to warfarin is surprisingly common and should be used with caution.

[Christopher Alvarez]

Yeah, aspirin's also commonly added DOAC therapy. Without a clear indication, we can discourage.

[Valeria Vasquez]

Inappropriate use of antiplatelet agents in our patients to better balance benefits and harms.

[Steve Brown]

Before starting antiplatelet or anticoagulant therapy assess ongoing bleeding risk.

[Christopher Alvarez]

Combined antiplatelet therapy with anticoagulation therapy should be reconsidered and only prescribed in specific evidence based situations.

[Valeria Vasquez]

Make sure to consider the whole person and share a decision with your patients about the benefits and harms of antiplatelet agents.

[Christopher Alvarez]

Maybe you can stop some of these meds in some of your patients, especially older ones with more bleeding risk.

[Steve Brown]

Yeah, be a med stopper. Deprescribing for the win. We'll be right back.

[Podcast Host/Announcer]

The AFP podcast is brought to you by the American Academy of Family Physicians and by the AAFP's upcoming Family Centered Pregnancy Care course, happening August 25th through the 28th in Denver, Colorado. Arrive early for advanced life support obstetrics courses for providers and instructors. Register [e-mail] fcpc2025.

[Steve Brown]

Our next topic is Long Term Opioid Therapy for Non terminal pain from Drs. Tsunoda and Wakabayashi.

[Christopher Alvarez]

Prescription opioid use has dropped by half over the last decade, but it's still common. Over 22% of adults with chronic pain report using a prescription opioid in the past three months, most often between the ages of 45 and 64.

[Steve Brown]

Since 1999, opioids have contributed to almost 300,000 overdose deaths in the United States, so family physicians are under immense pressure to balance effectiveness, safety and patient expectations.

[Valeria Vasquez]

Before we even talk about prescribing, we need to talk about inequity. Racial and ethnic minorities, women, older adults, transgender individuals, and those with cognitive impairment or mental illness are less likely to receive adequate pain treatment.

[Steve Brown]

Yeah, and more likely to have their opioid therapy abruptly discontinued, especially if there's a history of substance use. It's not just poor access, it's active bias.

[Christopher Alvarez]

Yeah, and cultural beliefs matter here too. Some patients are taught to endure pain, not report it. So step one is acknowledging these barriers and providing solutions like interpreters, financial support and mental health access.

[Valeria Vasquez]

Opioids should not be first line for chronic non terminal pain. They're an option only when other treatments fail or can't be used. And even then they come with caveats.

[Steve Brown]

There's only a small improvement in pain and function from opioid use. They're actually not better than NSAIDs, antidepressants or anticonvulsants. And studies rarely go beyond six months.

[Christopher Alvarez]

But patients are often perceiving benefits beyond the data, such as better sleep, less suffering. We need to acknowledge their lived experience even as we stay grounded in evidence.

[Valeria Vasquez]

Now let's run through the Risks. Constipation is common.

[Christopher Alvarez]

Depression is often triggered or worsened.

[Steve Brown]

Hormonal suppression can lead to sexual dysfunction and infertility.

[Valeria Vasquez]

Opioid induced hyperalgesia is a thing.

[Steve Brown]

Yeah, and let's not forget withdrawal, misuse and overdose.

[Christopher Alvarez]

Yeah. So all these things are why we screen carefully. And useful tools, including the DIRE score, which stands for diagnosis, intractability, risk and efficacy, can assess the risk of opioid misuse.

[Steve Brown]

Make sure you use your MME or your morphine milligram equivalent calculators to assess opioid potency.

[Valeria Vasquez]

And we can assess risk factors like CO prescribing benzodiazepines or untreated psychiatric disorders.

[Christopher Alvarez]

So how do we do it safely? I think we should start with realistic goals. Not necessarily pain free, but maybe able to walk a block or sleep through the night.

[Valeria Vasquez]

Use immediate release opioids, not extended release. Familiarize yourself with your state's PDMP and always screen for anxiety, depression and substance use using tools like the phq2 and gat2.

[Steve Brown]

And if opioid misuse happens, don't cut and run. Avoid abrupt discontinuation as it can worsen outcomes.

[Christopher Alvarez]

Instead, ask open ended questions. Misuse doesn't always mean addiction, but if OUD is suspected, treat it accordingly.

[Valeria Vasquez]

Now let's talk about buprenorphine. As a partial agonist, it offers pain relief with lower overdose risk and it's ideal for patients with opioid use disorder or high misuse risk.

[Steve Brown]

Transdermal buprenorphine works for lower dose needs, which is less than 30 morphine milligram equivalent.

[Christopher Alvarez]

Sublingual versions work for higher dose patients but require careful induction to avoid precipitated withdrawal.

[Valeria Vasquez]

It's also a solid option for complex persistent opioid dependence, such as those patients who decline functionally and emotionally after tapering but don't meet full criteria of opioid use disorder.

[Steve Brown]

When opioids no longer help or risks outweigh benefits, it's time to taper. But slow is safer. Think months to years, not weeks.

[Christopher Alvarez]

Support them psychologically as well. Address the depression, anxiety and social stressors if they're there and combine cognitive behavioral therapy, physical therapy and mindfulness to fill the voids opioids often leave behind.

[Valeria Vasquez]

Yes, and most importantly, shared decision making every step of the way. Managing chronic pain is never simple, but when we combine evidence with empathy and stay open to alternatives like buprenorphine, we can improve outcomes.

[Steve Brown]

My favorite segment Medicine there's so many of my favorite segments, but medicine by the numbers is one of my favorite segments. Fedaxomycin versus Vancomycin for the treatment of C. Diff infection and this is written by doctors Johari and Sklar from New York.

[Christopher Alvarez]

C. Diff infections, both primary and recurrent, are on the rise within healthcare settings. Standard treatment options, including metronidazole in vancomycin, are increasingly limited in their efficacy.

[Valeria Vasquez]

IDSA guidelines currently recommend phydoxomycin over vancomycin for the treatment of initial and recurrent.

[Christopher Alvarez]

C. Diff infections, and this meta analysis investigated the effectiveness of multiple antibiotics for the treatment of C. Diff infections. The primary outcome here was sustained symptomatic care and this was reported as a number needed to treat for patients with resolution of diarrhea at the end of treatment, minus the patients who had recurrence of diarrhea or who died from follow up.

[Steve Brown]

Fidaxomycin has a number needed to treat of 16 when compared to vancomycin for that endpoint and this was moderate quality evidence. In mild to moderate cases of C. Diff infection, fidaxomycin was also superior to vancomycin. However, there's equal effectiveness in severe cases of C. Diff.

[Valeria Vasquez]

Limitations of this study include no reported rates of adverse events and lack of long term evidence. IDSA guidelines currently acknowledge Access to thadoxomycin varies based on resources, medical insurance and.

[Christopher Alvarez]

Costs, and some of that cost. For example, a course of thadoxomycin is about $5,100 compared to 40 bucks for vancomycin and that's because of a lack of generic form availability. Overall, the color recommendation was given a green, meaning the benefits outweigh harms for using phytoxomycin treatment compared to vancomycin treatment for C. Diff infections.

[Steve Brown]

It's time for a steps Lecanumab for the slowing of Alzheimer's disease from Drs. Hull and Adelman from Columbus and Akron, Ohio. Today's new drug review is brought to you by the letters S, T, E, P and S. Steps is Safety, Tolerability, Effectiveness, price and simplicity. That was for your last podcast.

[Valeria Vasquez]

Guys.

[Additional Staff/Guest]

Love it.

[Steve Brown]

Today the medication we're discussing is lecanemab, labeled for the treatment of Alzheimer's disease in adults with mild cognitive impairment or who are in the mild dementia stages of Alzheimer with a mini mental status examination score of 20 to 28. Importantly, patients also have to have confirmed amyloid beta pathology. Okay, Valeria, tell us about the S the safety of lecanemab.

[Valeria Vasquez]

Yes, so patients get an MRI before therapy and then periodically during the therapy. Amyloid related imaging abnormalities occur in up to 20% receiving lecanemab and can result in headaches, mental status changes, confusion, tremors and gait disturbances with a number needed to harm of 36. APOE 4 testing may identify patients at higher risks of these abnormalities, but this test is not widely available. Intracerebral hemorrhage occurs in less than 1% of treated patients.

[Steve Brown]

Christopher, what about the tolerability of lecanemab?

[Christopher Alvarez]

Well, infusion related reactions occur in more than 20% of patients and most are mild to moderate. Seven percent of patients stop treatment compared to 3% with placebo with the number needed to harm of 25.

[Steve Brown]

Okay, I'll try to tackle the E effectiveness. There's two studies that they reviewed here. The first study is eight hundred and fifty six patients who showed no changes in cognitive scale scores exceeding the threshold of minimally important clinical difference. The second study of almost 1800 patients prevented worsening by 0.45 points compared to placebo on an 18 point scale. One point out of 18 is considered clinically relevant. So Valeria, what about The P price?

[Valeria Vasquez]

$27,000 per year for patients average weight, which does not include the costs for regular MRIs or medical appointments to address drug effects.

[Christopher Alvarez]

And the last ASIN here is for simplicity, lecanemab is infused over one hour every two weeks. Regular MRIs are performed at baseline and then before the 5th, 7th and 14th infusion.

[Steve Brown]

Okay, so bottom line, this drug is expensive with noteworthy risks.

[Valeria Vasquez]

Patients need to have early disease and confirmed amyloid plaques.

[Christopher Alvarez]

Families and patients seriously need to understand the ratio of benefit to risk care.

[Valeria Vasquez]

Please email [e-mail] or tweet FPpodcast.

[Podcast Producer/Additional Staff]

Please rate and comment wherever you get your podcasts.

[Christopher Alvarez]

Escucha nos en espanol en Revista America A FF PE Our podcast team is.

[Podcast Producer/Additional Staff]

Christopher Alvarez, Jake Anderson, Steve Brown, Sarah.

[Valeria Vasquez]

Coles, Marion Dawson, Hailey Hochstein, Nadia Mohamed, Satyam Patel, Valeria Vasquez, Sydney Vowles, and Sierra Voy.

[Podcast Producer/Additional Staff]

Our sound and technical guru is Tyler Coles. Our theme song is written and recorded by family physicians Bill Dabs, Ryan Evans and Justin Jenkins. This podcast is brought to you by the residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine Residency.

[Christopher Alvarez]

We'll talk to you soon for the next edition of the American Family Physician Podcast.