AFP Podcast Episode 235 – August 2025, Part 1: Clinical Pearls & Evidence Updates

Podcast: American Family Physician Podcast
Host: University of Arizona College of Medicine-Phoenix Family Medicine Residency
Contributing Editor: Dr. Steven Brown
Release Date: August 19, 2025

Overview

In this episode, the AFP Podcast team (Steve, Rachel, and Kari) highlights key clinical points from the August 2025 issue of American Family Physician. They break down new guidelines, recent evidence, and best practices on the following topics:

• Heart failure with reduced ejection fraction (HFrEF)
• The Oakland score for lower GI bleeding
• Compression therapy for venous leg ulcers
• Non-opioid pharmacologic management of chronic pain
• Burn resuscitation guidelines
• Active monitoring for low-risk ductal carcinoma in situ (DCIS)

Main Discussion Points & Insights

1. Heart Failure with Reduced Ejection Fraction (HFrEF) Management

From Drs. Gower, Refot, and Falkrod – Womack Army Medical Center, NC

Key Discussion:

• Foundations of Guideline-Directed Medical Therapy (GDMT):

  • Four pillars:
    1. RAS inhibitors (ARNI/ARBs/ACEi)
    2. Beta blockers
    3. Mineralocorticoid receptor antagonists (MRAs, e.g., spironolactone)
    4. SGLT2 inhibitors
       (02:04) Steve: “Don’t forget our tried and true pillars of Goal-Directed Medical Therapy... those are your ARNIs, ARBs, and ACE inhibitors...”

• Titration:

  • Aim to titrate all four classes within 6–12 weeks of diagnosis (02:43).
  • Sequence isn’t standardized, but starting with beta blocker/SGLT2 inhibitor is proposed to reduce sudden death/rehospitalization.

• Effectiveness:

  • Combining all four classes reduces all-cause mortality by 61% and adds 7.9 years of life for a 50-year-old (03:22).

• Common Side Effects:

  • Hypotension and hyperkalemia are most common; manage accordingly with close monitoring (03:28).

• Role of Diuretics:

  • Primarily for symptom management—not disease progression (03:58).

• Hospitalization:

  • Do not stop beta blockers during exacerbations if the patient is already on them (04:24).

• Iron Deficiency:

  • IV iron may improve functional status but does not reduce cardiovascular death/hospitalizations (04:45).

2. The Oakland Score for Lower GI Bleeding

Medicine by the Numbers, from Drs. Evan Xiao and Yousef – Kings County, Brooklyn

Key Discussion:

• Purpose:

  • Tool to predict safe discharge and major risks in patients with lower GI bleed.

• Evidence:

  • Lacks robust discriminatory power:
    • Major Bleeding: Sensitivity 97%, specificity 9% for score >8—defined as “not really helpful” (06:17).
    • Safe Discharge: Sensitivity 10%, specificity 97% for score <=8—again, not helpful.

• Conclusion:

  • Must use in conjunction with clinical judgment.
    (07:03) Kari: “...the American College of Gastroenterology recommend using this risk tool in combination with clinical judgment.”

3. Compression Therapy for Venous Leg Ulcer Recurrence

Cochrane for Clinicians, from Drs. Gregory and Epling – Roanoke, VA

Clinical Question:
Do compression stockings prevent recurrence of lower extremity venous ulcers?

Key Discussion:

• Evidence Review:

  • Based on eight trials, most with bias limitations (07:55).

• Best Practice:

  • Heavy (30–40 mmHg) compression reduces re-ulceration over 6 months, NNT=5 (08:14).
  • Long-term: Medium to heavy compression more effective than light to medium (absolute risk reduction 18.8%, NNT=6).

• Tolerability:

  • Higher dropout with higher compression (NNT to harm=14). Many patients struggle with adherence.

• Bottom Line:

  • Lifelong compression recommended; select heaviest compression tolerated. (09:47) Rachel: “Use lifelong compression, ideally with heavy compression. But if patients don’t tolerate heavy compression, medium compression may be similar in efficacy...”

4. Non-Opioid Pharmacologic Management of Chronic Non-Cancer Pain

From Dr. Sokol, Grossman, and Burgery – Cambridge Health Alliance, MA

Key Discussion:

• Epidemiology:

  • 1 in 5 U.S. adults affected; leading cause of disability (10:47).

• Principles:

  • Multimodal, individualized, and functional-goal oriented care.

• Medications by Condition:

  • Neuropathic Pain:
    • Duloxetine (60mg): NNT=5 for ≥50% pain reduction.
    • Gabapentin/Pregabalin: Moderate relief; dizziness/somnolence common (11:57).
  • Fibromyalgia:
    • Pregabalin, duloxetine, milnacipran effective, but NNTs relatively high (12:13).
  • Osteoarthritis:
    • Topical NSAIDs (e.g., diclofenac) first line for knee/hand OA (NNT=10).
    • Duloxetine may benefit select patients (NNT=6 in responders).
    • Avoid acetaminophen, glucosamine/chondroitin.
  • Low Back Pain:
    • Oral NSAIDs: Small, low-quality benefit.
    • Gabapentinoids, TCAs, SSRIs/SNRIs: Not beneficial, should be avoided (13:44).
    • Muscle relaxants: Only for short-term, acute use (<3 weeks).

• Generalized Chronic Pain:

  • Duloxetine, milnacipran can help multiple conditions.

• Topicals:

  • Capsaicin cream: NNT=6–8, but 1/3 experience burning.
  • Lidocaine: Lacks high-quality evidence (14:52).

Quote:
(15:01) Rachel: “...chronic pain management is about functional outcomes using evidence-informed, patient-centered and multimodal strategies.”

5. Burn Resuscitation – New Guidelines

Practice Guideline, American Burn Association – Dr. Nelson, Michigan State

Key Discussion:

• Trustworthiness:

  • American Burn Association guideline gets “5 yes, 2 no, 1 unknown” on G Trust Scorecard.

• Cautions:

  • Limited evidence—view as clinical suggestions, not absolute rules.
    (15:56) Rachel: “As pointed out by the AFP’s assistant medical editor... recommendations should be considered more as suggestions than firm guidance.” (16:08) Steve: “Guidelines are not godlines.”

• Protocol:

  • Use Parkland formula for TBSA estimation.
  • Initial resuscitation: 2 mL/kg x %TBSA burn in first 24 hours.
  • Consider albumin for large burns as adjunct.
  • Goal urine output: 0.5 mL/kg/hr.
  • Consider, but don’t rely on, decision support software.
  • Avoid fresh frozen plasma.
  • High dose vitamin C: Benefit uncertain.
  • No recommendation on continuous renal replacement therapy.

6. Practice-Changing POEM: Active Monitoring vs. Surgery for Low-Risk DCIS

POEM by Dr. Slauson

Study Design & Results:

• 957 women with low-risk DCIS:
  • Randomized to active monitoring vs. usual care (surgery ± radiation).
  • 2-year follow-up:
    • Invasive cancer rates: 4.2% (active monitoring) vs. 5.9% (surgery/radiation)
    • All-cause mortality: No difference

Conclusion:
Active monitoring is not inferior to surgery in carefully selected women with low-risk DCIS.
(18:18) Steve: “Active monitoring might be a good plan for your patient. And I really like the term active monitoring. I think patients might like it better than watchful waiting.”

Notable Quotes & Memorable Moments

• On GDMT for HFrEF:
  (03:23) Kari: “Practically speaking, this adds an additional 7.9 years of life for a 50 year old patient.”

• On Oakland Score:
  (06:26) Kari: “That’s like a positive likelihood ratio of 1.07. That’s not really helpful.”

• On Compression Stockings:
  (09:44) Kari: “Those things are hard to get on your legs.”
  (09:22) Steve: “Have you ever tried to wear compression stockings all day, especially in the summer? Ish.”

• On Guideline Limitations:
  (16:08) Steve: “Guidelines are not godlines.”

• On Chronic Pain Management:
  (15:01) Rachel: “Chronic pain management is about functional outcomes using evidence-informed, patient-centered and multimodal strategies.”

Timestamps for Key Segments

• Heart failure with reduced ejection fraction: 01:32 – 05:14
• Oakland score for lower GI bleed: 05:14 – 07:12
• Compression therapy, venous leg ulcers: 07:12 – 10:12
• Non-opioid management of chronic pain: 10:30 – 15:19
• Resuscitation in burns: 15:19 – 17:14
• Active Monitoring in DCIS: 17:19 – 18:18

Summary

This episode delivers evidence-based updates in a conversational and approachable way. The hosts review major clinical takeaways for practice, continually emphasizing functional outcomes, shared decision-making, and the importance of personalized, guideline-directed care. They also maintain a lively and collegial tone, sprinkling in humor and memorable quotes that reinforce the teaching points. Whether reviewing a guideline or discussing chronic pain management, the bottom line is clear: evidence and patient goals must always guide family medicine practice.