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

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.

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)

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)

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)

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)

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.

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.

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)

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

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.