Episode 247 -- February 2026 -- Part 1 AFP: American Family Physician

Summary

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AFP: American Family Physician Podcast

Episode 247 — February 2026, Part 1
Date: February 16, 2026
Hosts: Steve, Emily, Austin
Podcast by: University of Arizona College of Medicine-Phoenix Family Medicine Residency (for AAFP)

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Episode Overview

This episode delivers key evidence-based clinical updates pulled from the February 2026 issue of American Family Physician. Hosts Steve, Emily, and Austin break down new practice recommendations, share practical pearls, and walk through memorable case scenarios as they hit on major primary care topics: menopause management, pediatric wheezing, NSAID-induced ulcers, infective endocarditis, acute migraine management, and colchicine for secondary ASCVD prevention.

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Key Topics and Insights

1. Menopause Management: When Hormone Therapy is Appropriate

[00:31–04:00]

• Guideline Updates:
  • Systemic hormone therapy for vasomotor symptoms has benefits that outweigh risks in women younger than 60 or within 10 years of menopause onset if no contraindications.
    • “Guidelines from the Menopause Society and NICE in the UK clearly state that the benefits of systemic hormone therapy for the treatment of vasomotor symptoms outweigh the risks in women younger than 60 or within 10 years of menopause onset.” — Emily [01:49]
• Contraindications include:
  • Hx of breast cancer/estrogen-sensitive neoplasia
  • VTE, stroke, CAD
  • Active liver disease, uncontrolled hypertension, unexplained vaginal bleeding
  • Relative contraindications: migraine with aura, high CVD or VTE risk, certain family cancer histories
• Approach in Four Steps:
  1. Screen for contraindications
  2. Engage in shared decision-making
  3. Reassess annually
  4. Taper when risk > benefit (typically starting at age 60)
  • “We can always help a patient take an individualized approach to treatment in four easy steps.” — Steve [02:58]
• Memorable Chart:
  • Example: Fracture risk ↓ 230/10,000, but VTE ↑ 120/10,000 with combined estrogen/progestogen.
  • “We need to laminate it, hang it in the Louvre.” — Austin [03:45]
• Pearl: Shared decision making may reduce unsafe use of compounded bioidentical hormones.

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2. Wheezing in Children: Diagnostic Pearls

[04:00–08:23]

• Major Insight:
  • “Just because a kid wheezes does not mean they have asthma.” — Austin [04:09]
  • Only 30% of preschoolers with recurrent wheezing are diagnosed with asthma by age 6.
• Common causes:
  • Asthma, bronchiolitis, transient viral wheezing, GERD, congenital anomalies
• Family history importance:
  • Parental asthma or eczema = 4x odds for child to have asthma.
• Practical Case Discussion Highlights:
  • First-time wheezing with fever (7mo, fall/winter): Likely viral (RSV, rhinovirus, flu).
  • Wheezing post feeds (2mo, persistent): Think GERD; if unresponsive to PPI → consider congenital causes (e.g. TE fistula, vascular ring).
  • Position-exacerbated wheezing: Suggests tracheomalacia (workup: bronchoscopy).
  • Sudden unilateral wheezing: Suspect foreign body aspiration (boys 1–3 yrs) or anaphylaxis.
  • Frequent/prolonged infections: Work up for CF or immunodeficiency.
  • Nocturnal cough, exertional dyspnea, recurrent wheezing (>4yr): Clinical asthma, consider spirometry.
  • Asthma plus snoring/worsening wheeze (7yr): Raise suspicion for OSA (tonsillar hypertrophy, craniofacial).
• Key Diagnostic Test:
  • “For any kid with recurrent or persistent wheezing, a chest X-ray should be that first study.” — Emily [08:09]

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3. Prevention of NSAID-Induced Ulcers: Medicine by the Numbers

[08:23–10:44]

• Evidence Overview:
  • 12 RCTs, ~8,700 long-term NSAID users: PPIs vs. placebo, H2 antagonists or misoprostol.
  • PPIs decrease ulcer incidence (NNT = 12), reduce dyspepsia and modestly improve QoL compared to placebo.
• Comparison Caveats:
  • Little/no difference between PPIs and H2 blockers.
  • Slightly higher ulcer incidence with PPIs vs. misoprostol, but more side effects with misoprostol.
• Limitations:
  • Most studies <12 months duration; high risk of bias (pharma sponsorship).
• “Most of these studies were at high risk of bias, including bias due to pharmaceutical sponsorships.” — Steve [10:10]

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4. Infective Endocarditis: Diagnosis and Treatment Updates

[11:07–16:54]

• Case-Based Learning:
  • 65yo man (ESRD, pacemaker) with weeklong fever, new holosystolic murmur, meets SIRS: suspect endocarditis.
• Evaluation Approach:
  • Findings like new/worsened murmur key—continuity of care helps catch changes.
  • Classic signs (Osler nodes, etc) rare (<10%).
  • Risk factors: Valvular/prosthetic disease, cardiac devices, immunosuppression, GI/dental disease, IV drug use, dialysis.
• Diagnostics:
  • Start with transthoracic echo (TTE) (94% specific, but misses 40%).
  • If negative but suspicion is high: TEE (92–96% sensitive). Adjunct: cardiac CT/MRI/PET.
  • “A specific test rules a condition in—SPIN. A sensitive test can rule something out—SNOUT.” — Steve [13:34]
• Diagnostic Criteria:
  • 2023 Duke criteria: combine risk factors, exam, imaging, microbiology to classify as definite/possible/rejected. Use calculators!
• Empiric Management:
  • Native valve: Vancomycin + Ceftriaxone.
  • IV antibiotics ≥10 days, total 4+ weeks (native), 6+ weeks (prosthetic).
• Escalation:
  • Lack of improvement (bacteremia, persistent fever >5d, heart failure/valve dysfunction) → consider valve surgery.
• Prevention:
  • Counsel on risk factors and dental hygiene.
  • Antibiotic prophylaxis: amoxicillin (alternatives: cephalexin, doxy, azithro) before high-risk dental procedures if prosthetic valves, prior endocarditis or device.
  • No longer recommended for GI/GU/endoscopy procedures.
• Sobering Stats:
  • “Despite treatment advances, infective endocarditis is still a high risk diagnosis with in-hospital mortality around 15–20% and 1-year mortality of 30–40%. Yikes.” — Austin [16:54]

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5. Acute Migraine Treatment: International Headache Society Guidelines

[17:17–20:37]

• Guideline Quality:
  • 5/8 G Trust score: evidence ungraded, COI present.
• Key Principles:
  • Timing: Abortive meds best early in pain phase, NOT during prodrome/aura.
    • “That’s a really important counseling point since many of our patients obviously want to treat that migraine before it fully starts.” — Emily [17:59]
  • Limitations:
    • Analgesics: max 3 days/week or 10 days/month
    • Triptans: max 2 days/week or 8 days/month
  • Medication Selection:
    • Analgesics: effective, good for kids; use caution in elderly and pregnancy.
    • Triptans: more effective, but try 2 types before changing class (dose escalation rarely helps).
    • About 40% migraine relapse after triptan; longer-acting agents or combo with naproxen reduce relapse.
    • Newer “Gepants”: less risk for overuse headache, can be taken during prodrome/early aura.
• Special Cases:
  • Status migrainosus: Consider IV prochlorperazine or metoclopramide; steroids, IV Mg, or sodium valproate—limited evidence.
  • Menstrual migraine: More severe; try long-acting triptan or NSAIDs pre-menses.
  • Pregnancy: 90% improve, 8% worsen. Preferred: acetaminophen, avoid NSAIDs, sumatriptan can be considered.
• “Migraines can be a pain for patients and physicians.” — Austin [17:29]

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6. Colchicine for Secondary Prevention of Cardiovascular Disease

[20:45–23:29]

• Evidence Summary:
  • Meta-analysis (9 trials, >30,000 pts):
    • Composite endpoint reduction (CV death/MI/stroke)
      • NNT = 114 (modest absolute benefit)
    • Only MI reached statistical significance; no change in all-cause mortality
    • GI events more common with colchicine (NNH = 181)
  • “High level evidence for slight benefit with some harm.” — Emily [22:04]
• Shared Decision Making Essential:
  • “Mixed finding”—weigh small benefits against potential harm.
• Historical/Pharma Note:
  • Colchicine approved for gout only in 2009; brand name for 0.5mg dose (Lodoko) is expensive ($390–$550/month); 0.6mg generic is much cheaper ($14/month) and also endorsed as valid by AHA/ACC guidelines.
  • “Colchicine is one of the oldest medicines on the planet... described in the first century.” — Steve [22:19]
  • “Surprise, surprise. More drug company shenanigans.” — Austin [23:27]

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Notable Quotes & Memorable Moments

• “We need to laminate it, hang it in the Louvre.” — Austin [03:45], on practical menopause hormone therapy chart.
• “Just because a kid wheezes does not mean they have asthma.” — Austin [04:09]
• “A specific test rules a condition in—SPIN. A sensitive test can rule something out—SNOUT.” — Steve [13:34]
• “Despite treatment advances, infective endocarditis is still a high risk diagnosis with in-hospital mortality around 15–20% and 1-year mortality of 30–40%. Yikes.” — Austin [16:54]
• “Migraines can be a pain for patients and physicians.” — Austin [17:29]
• “Surprise, surprise. More drug company shenanigans.” — Austin [23:27]

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Segment Timestamps

| Topic | Timestamp | | ----------------------------------------|:------------: | | Menopause Management | 00:31–04:00 | | Wheezing in Children | 04:00–08:23 | | NSAID-Induced Ulcer Prevention | 08:23–10:44 | | Infective Endocarditis | 11:07–16:54 | | Migraine Treatment Guidelines | 17:17–20:37 | | Colchicine for ASCVD Prevention | 20:45–23:29 |

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Summary prepared for clinicians who want key takeaways and practice-impacting pearls from the February 2026 Part 1 episode of the AFP Podcast.

Transcript

[Podcast Announcer]

The AFP podcast is brought to you by the American Academy of Family Physicians and by Elation Health. Elation is an AI powered EHR that helps primary care practices spend less time on documentation and admin tasks and more time on what truly matters, caring for patients and nurturing meaningful relationships. Visit elationhealth.com afp to learn how you can save time.

[Steve]

Welcome to the American Family Physician podcast for part one of the February 2026 issue. I'm Steve.

[Emily]

I'm Emily.

[Austin]

And I'm Austin.

[Steve]

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 menopause management, wheezing in children, prevention of NSAID induced ulcers, infective endocarditis, acute migraine treatment, and colchicine for secondary prevention of cardiovascular disease.

[Emily]

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.

[Steve]

We're on a mission delivering the best from American family. Let's start with an editorial Menopause Management When Hormone Therapy is Appropriate. This is from Drs. Bass and Casper from New Jersey and North Carolina.

[Austin]

Menopausal symptoms can profoundly impact quality of life in many women.

[Emily]

Definitely. Guidelines from the Menopause Society and NICE in the UK clearly state that the benefits of systemic hormone therapy for the treatment of vasomotor symptoms outweigh the risks in women younger than 60 or within 10 years of menopause onset.

[Steve]

Okay, so 60 or within 10 years of menopsause onset. This is definitely a practice change for some of us that have been around for a while, which is the whole point of this editorial.

[Emily]

Definitely.

[Steve]

So as long as there's no contraindications.

[Austin]

Remember that for patients with an intact uterus, a progestogen must also be prescribed along with systemic estrogen.

[Emily]

And let's remind ourselves, what are the contraindications to systemic estrogen therapy?

[Steve]

There's quite a few history of breast cancer or other estrogen sensitive neoplasia, venous thromboembolism, stroke, coronary artery disease.

[Austin]

And that's not all. Active liver disease, uncontrolled hypertension and unexplained vaginal bleeding are other contraindications as well.

[Emily]

And then some relative contraindications include things like migraine with aura, controlled hypertension, hypertriglyceridemia, certain cancer family histories, and high cardiovascular or Venous thromboembolism risk.

[Steve]

We can always help a patient take an individualized approach to treatment in four easy steps.

[Austin]

Step one, screen for contraindications.

[Emily]

Step two, engage in shared decision making.

[Steve]

Step three, reassess regularly monitoring risks and benefits annually.

[Austin]

And step four, consider tapering when risk begins to outweigh the benefits annually starting at age 60.

[Emily]

There's a really great table here that shows absolute harms or benefits for lots of conditions and the effect size and.

[Austin]

For example, fractures are decreased by 230 per 10,000 over 5.6 years. With combined estrogen and progesterone, venous thromboembolism.

[Steve]

Is increased by 120 per 10,000 with the same medicine and time period.

[Emily]

This is a really great chart.

[Austin]

We need to laminate it, hang it in the louvre.

[Emily]

By helping our patients make evidence based decisions, they might be less likely to use unregulated compounded bioidentical hormones.

[Austin]

Yeah. A family medicine shared decision making for the win again.

[Steve]

Next, wheezing in Children from Drs. Cagle, Hornsby and Chin from Offut Air Force Base Family medicine residency in Nebraska.

[Austin]

All right, here's my big takeaway from this article. Just because a kid wheezes does not mean they have asthma.

[Steve]

Yeah, yeah.

[Austin]

Only about 30% of preschool age children with recurrent wheezing get diagnosed with asthma by age six.

[Emily]

But hold on, don't get ahead of yourself. Asthma is still one of the most common causes of wheezing in kids under six, along with bronchiolitis. The real takeaway here is doing a thorough history. Family history transient versus that persistent wheezing. And when the wheezing truly started.

[Steve]

Exactly. Parental asthma or eczema increases a child's likelihood of asthma. With an odds ratio of 4.19. Transient wheezing is often viral. Persistent wheezing, especially since infancy, should raise concerns for congenital causes.

[Austin]

Got it. Maybe we should run through some cases.

[Emily]

Yeah, sure. So you're in the pediatric ed in, oh, late November. Your seven month old patient has a fever and wheezing for the first time.

[Austin]

Well, this sounds viral. Rsv. If they didn't get the rsv, preventative antibody nircivimab. But flu or rhinovirus still are possible.

[Steve]

Yes. Okay, so for our next case, a two month old in July, you hear wheezing on exam and the parents just fed her before the visit and she's been increasingly spitting up.

[Austin]

While I think common things being common, I think GERD or gastroesophageal reflux disease, especially if the Wheezing follows feeds. I'd want to trial a proton pump inhibitor first.

[Emily]

Certainly reasonable, but what if four weeks later, she's still wheezing and regurgitating with FEEDS despite that PPI therapy?

[Austin]

Ooh, then I think I'd have to worry about maybe something congenital, like esophageal atresia, a tracheoesophageal fistula or a vascular ring.

[Emily]

Perfect. GERD is still most likely. Like you said, esophageal atresia is less likely since it's usually caught shortly after birth.

[Steve]

Cardiac etiologies account for less than 1% of wheezing, and you'll need a CT for workup of that, but that should definitely be in the differential.

[Emily]

And if you still suspect GERD and that PPI did not help, you can consider a 24 hour ph monitor or endoscopy as further workup.

[Steve]

All right, so we gotta keep this moving. The wheezing differential is long. Next up, another two month old whose wheezing worsens when lying flat.

[Austin]

Hmm. I think tracheomalacia is what I remember from step one, where the airway collapses with position changes.

[Steve]

And diagnostic evaluation would be bronchoscopy. So now we have a two year old boy with sudden unilateral wheezing. Emily.

[Emily]

Yeah, this is a worrisome one. I'd be concerned about foreign body aspiration, which is most common in boys ages 1 through 3.

[Steve]

All right, nailed it, Emily. But don't forget anaphylaxis, which should always be in the differential for sudden onset respiratory symptoms. Okay, so, Austin, now you have a four year old with frequent prolonged respiratory infections.

[Austin]

Oh, I don't like the prolonged infections. I think I'm remembering cystic fibrosis or another immunodeficiency disorder. And.

[Steve]

Yeah, that's great. So another patient. They're coming rapid fire here into your. Into your emergency room. The next patient is a four and a half year old with a nocturnal cough, exertional dyspnea, and recurrent wheezing.

[Emily]

Now that sounds like asthma. A clinical diagnosis in young children. Something to remember over the age of four. Spirometry and bronchodilator testing can help, per the 2007American Thoracic Society guidelines.

[Steve]

Great. So last case, seven year old with asthma, worsening, snoring, and persistent recurrent wheezing.

[Austin]

Wait, I got this. I just did my sleep medicine rotation. This might be sleep apnea. Kids with wheezing in the past 12 months have a higher prevalence of snoring and nighttime awakenings and Poorly controlled asthma increases risk of tonsillar hypertrophy and therefore obstructive sleep apnea. These kids should also be evaluated for other craniofacial abnormalities.

[Steve]

All right, that is all the cases. Well done team.

[Emily]

Well, one last clinical pearl for any kid with recurrent or persistent wheezing, a chest X ray should be that first study. It can reveal cardiomegaly hyperinflation, vascular abnormalities or a foreign body. So very useful.

[Steve]

Now it's time for a medicine by the numbers PBIS for prevention of NSAID induced gastric or duodenal ulcers and dyspepsia from Drs. Rogers and north from Charleston, South Carolina.

[Austin]

Given the known elevated incidence of upper gastrointestinal bleeding and perforation in patients taking nonsteroidal anti inflammatory drugs, the present Cochrane review analyzed 12 randomized control trials which randomized 8,760 adult outpatients taking long term NSAIDs to receive a proton pump inhibitor versus placebo, an H2 agonist or misoprostol.

[Emily]

The primary efficacy endpoints were dyspepsia, symptom burden, quality of life and ulcer incidence, certainly things we care about for our patients. The harm endpoints were incidents of adverse events and ulcer complications.

[Steve]

In this systematic review, the most robust analysis was on PPIs versus placebo, which was 11 of the 12 randomized trials. In these studies, PPIs reduced ulcer incidence with moderate certainty evidence and an NNT of 12 number needed treat of 12. Similarly, two of the randomized controlled trials provided moderate certainty evidence that PPIs reduced global dyspepsia symptom burden and contributed to a small increase in quality of life when compared to placebo.

[Emily]

What about when PPIs were compared to H2 blockers or misoprostol?

[Austin]

Well, the review of those studies produced low certainty evidence with little to no difference in ulcer incidence when comparing PPIs with famotidine and slightly higher ulcer incidence when comparing PPIs with misoprostol. However, those same RCDs also showed very low certainty evidence that there were fewer adverse effects with PPIs versus the nisoprostol.

[Steve]

As always, there are caveats. Most of these studies were at high risk of bias, including bias due to pharmaceutical sponsorships. The bias impacted the certainty of all the evidence analyzed, downgrading most recommendations.

[Austin]

Yeah, those pesky pharmaceutical companies. And another caveat was the studies had a follow up interval of less than 12 months which is long term. But practically speaking, patients who need long term NSAIDs for chronic disease management often need these meds for longer than just 12 months, which does limit the generalizability of these results.

[Emily]

We'll be back in a moment.

[Podcast Announcer]

The AFP podcast is brought to you by the American Academy of Family Physicians and by menopause and perimenopause CME for family physicians. A new live stream from the AAFP. Join us April 23rd through the 24th. Find [e-mail] menopause CME.

[Steve]

Okay, we're back for some infective endocarditis diagnosis and treatment. This is from Drs. Noria Romaine and Garcia Sampson from Duke University.

[Emily]

To highlight what's new on this topic, let's walk through a case.

[Steve]

Ooh, another case. Yay.

[Emily]

We have a 65 year old gentleman. He has ESRD and a pacemaker. He presents to you his PCP. He's got one week of fevers and malaise. On exam, you recognize a new holosystolic murmur. He looks ill, meeting SIRS criteria, so you decide to send him to the ED for further evaluation.

[Austin]

Yeah, the ED seems appropriate for this one, but let's take a pause. What clinical features should make us think about endocarditis for this patient?

[Emily]

So a new murmur, like in our patient, occurs in about 48% of patients with endocarditis, and a worsening of a known murmur occurs in about 20%. This really highlights the importance of continuity and care to recognize exam changes in your patients. Other findings can reflect microembolic or immunologic phenomena. Things like splinter hemorrhages, Osler nodes, Janeway lesions, all the things we memorized in medical school. But truthfully, these are uncommon and only seen in about 5 to 10% of cases. Risk factors that we should consider and raise the suspicion include valvular disease or a prosthetic valve implanted cardiac devices or congenital heart disease. And additional risk factors include immunosuppression, GI tract disruption, dental disease, IV drug use, dialysis, or indwelling catheters.

[Steve]

All right, so our patient is in the emergency department. The vitals and labs suggest infection. The urinalysis is negative. Blood cultures are drawn and pending. And we're concerned about endocarditis. How do we proceed with the diagnosis?

[Emily]

So a transthoracic echo is first line, but it can actually miss up to 40% of cases. But a positive transthoracic echo has about 94% specificity. If that TTE is negative and concern is high, then a transesophageal echo or TEE, has much higher sensitivity, around 92 to 96%. There are other studies like cardiac CT, CTA, MRI or PET scan. And these can help assess for complications and assist with surgical planning if needed.

[Steve]

Can I nerd out a little bit here?

[Emily]

I suppose we'll allow it.

[Steve]

So you, Emily, suggested using the less invasive test first. And it's pretty specific, so if you see a lesion, you're done. 94% specificity. A specific test, rules of condition in spin. But if you still have a high suspicion, you need a more sensitive test. If you don't see anything, it's probably not there. A sensitive test can rule something out. Snout.

[Austin]

Okay, so to make this diagnosis, are we still using the Duke criteria?

[Emily]

Yes. So the 2023 Duke criteria incorporate risk factors, clinical findings, imaging and microbiology results and will classify endocarditis as definite, possible or rejected. Possible endocarditis requires one major and one minor criterion or three minor criteria. These are much more expansive than what many of us memorized back in medical school. And thankfully, online tools and calculators are available.

[Austin]

Alright, I definitely need a calculator with all these new criteria. But it seems our patient meets these new criteria for possible endocarditis with three minor criteria. He has a fever, a new regurgitant murmur and a history of an implantable cardiac device. So while we wait for our cultures, in our final echo, what empiric antibiotics should we start for empiric therapy for.

[Steve]

Native valve endocarditis, your first line is vancomycin and ceftriaxone. There are other considerations like prosthetic valves or the source of the infection. The that will cause you to use different antibiotics empirically. First line. Once cultures return and antibiotics are tailored, targeted, when can we transition to oral therapy?

[Emily]

Great question. So at least 10 days of IV antibiotics is typical, but that's assuming no other complications. Total duration is at least four weeks for a native valve endocarditis and six weeks for prosthetic valves. But again, these recommendations are largely based on observational data, so infectious disease input is pretty important here.

[Austin]

Okay, I don't mean to be a cynic here, but what if our patient's not improving with those antibiotics? What if he's having persistent fevers, worsening shortness of breath or edema?

[Emily]

So persistent bacteremia, fevers beyond five days despite appropriate antibiotics, acute heart failure, valve dysfunction, all of those should really prompt considerations for the need for valve replacement.

[Steve]

After we've discharged our patient. What about preventing future infections?

[Emily]

This is a great question and I think something that we come across in the primary care setting quite frequently. So counseling on risk Factors and the importance of dental hygiene is really key. Antibiotic prophylaxis is recommended for high risk dental procedures, typically with a dose of amoxicillin 30 to 60 minutes prior. Alternative options include cephalexin, doxycycline or azithromycin if a patient has a penicillin allergy. Prophylaxis is recommended for patients with prior endocarditis and also for those with prosthetic valves or ventricular assist devices. Current guidelines no longer recommend prophylaxis for TEE endoscopy, colonoscopy or cystoscopy.

[Austin]

All right, guys, not to close this out on a downer, but. But despite treatment advances, infective endocarditis is still a high risk diagnosis with in hospital mortality around 15 to 20% and one year mortality of 30 to 40%. Yikes. Yeah. This is why staying up to date on prevention, diagnosis and management matters so much and is so important for us as family medicine physicians.

[Emily]

Definitely.

[Steve]

Now we have a practice guideline. Acute Migraine treatment Guidelines from the International Headache Society. This is from Dr. Arnold from the Naval Undersea Medical Institute in Connecticut.

[Austin]

Migraines can be a pain for patients and physicians. Let's talk through these treatment guidelines to better support our patients.

[Steve]

This guideline gets 5 out of 8 on the G Trust scorecard. Evidence is not graded by quality. There's lots of conflicts of interest. Both chairs of the guideline panel are paid by industry sources. These authors may have been influenced to present the newer medications more favorably. On the positive side, the guideline is focused on patient oriented outcomes and is.

[Emily]

Based on systematic reviews and still some good takeaways here. One key area is on medication timing. Abortive medications should be taken early when pain is still mild, but most typically actually aren't effective if taken during the prodrome or aura. That's a really important counseling point since many of our patients obviously want to treat that migraine before it fully starts.

[Steve]

I did not know that.

[Austin]

Yeah, that's a good pearl. Medication overuse is another challenge that we're very familiar with. In headache management, analgesics should be limited to three days per week or 10 days per month. And triptan should be limited to two days per week or eight days per month, which can be difficult for some patients.

[Emily]

And in terms of specific abortive medications, analgesics are really a great option. They're widely available, effective alone or as adjuncts, and can be pretty useful in children. Caution is obviously needed in older adults and in pregnancy. Triptans are more effective than analgesics alone, but for patients with only a partial response, it's important to note that increasing the dose really doesn't offer much benefit. The guidelines recommend trialing up to two other triptans before switching medication classes.

[Austin]

And when trialing triptans, it's important to counsel patients that about 40% will experience migraine relapse within 48 hours, but a second dose is often effective. Using longer acting triptans or combining triptans with naproxen can also help reduce relapse.

[Emily]

The Japant medications, which I just love saying it's amazing, they're another good option. They appear less likely to cause medication overuse, headache and this is an exception to what I said earlier. They can be taken during the prodrome or a phase and still provide relief.

[Austin]

Now status migranosis is something many of us see in the ED and unfortunately evidence is limited for this condition. IV prochlorperazine or metoclopramide appear somewhat effective. Evidence for steroids, IV magnesium and sodium valproate are limited.

[Emily]

Menstrual migraines tend to be more severe and refractory triptans may be less effective but can still help. Long acting triptans can be used preventatively started a few days before menses. NSAIDs like Naproxen or mefenamic acid may also be beneficial.

[Austin]

And let's not forget our pregnant patients, another important population in which migraines occur. Migraines improve in 90% of pregnant patients, though in 8% they worsen. For these patients, acetaminophen is preferred. An NSAID should generally be avoided. Sumatriptan appears to be a safe option and metoclopramide can be used for nausea. Evidence for triptans during lactation remains limited.

[Emily]

Got it. Well, these are great tips and hopefully will make migraines a little bit less of a pain for everyone.

[Steve]

Okay, we're going to close out part one with a poem. Poems are patient oriented evidence that matters. This poem is entitled Systematic Review Supports Colchicine for Secondary Prevention of Atherosclerotic Cardiovascular Disease. The question for you, Austin and Emily, is colchicine safe and and effective for the secondary prevention of atherosclerotic cardiovascular disease?

[Austin]

Well, it seems like the answer is yes, kind of. Based on a Systematic Review of nine trials with over 30,000 patients, the primary.

[Emily]

Outcome was a composite outcome of cardiovascular death, myocardial infarction and stroke.

[Steve]

This outcome occurred less in the colchicine group compared to placebo, with a number needed to treat of 114.

[Emily]

Only myocardial infarction had a statistical difference.

[Steve]

By itself there was no difference in all cause mortality.

[Austin]

So the trade off here is the rate of hospitalization for gastrointestinal events occurred more often in the colchine group with a number needed to harm of 181.

[Emily]

This is a well done meta analysis, level 1A evidence.

[Austin]

And remember, this is in patients with established atherosclerotic cardiovascular disease.

[Steve]

Dr. Slauson calls this this a mixed finding. So we should use shared decision making before prescribing colchicine for secondary prevention.

[Emily]

High level evidence for slight benefit with some harm.

[Steve]

Okay, I'm going to editorialize a little here. I was super curious about what's going on because colchicine is one of the oldest medicines on the planet. It was described in the first century.

[Austin]

Wow.

[Steve]

Yeah, for gout treatment. But remarkably, colchicine was not FDA approved for gout until 2009. And then after approval there was only brand availability and the price went way up. I know. So the dose for colchicine used in these recent cardiovascular trials is 0.5 milligrams, which shocker is only available in brand, not generic. It's called brand name Lodoko. And get ready for this on goodrx.com it costs $390 to $550 per month. It's FDA approved for cardiovascular prevention. However now thank goodness, since the mid-2010s you can prescribe good old fashioned generic colchicine 0.6 milligrams for $14 per month. And so you're like well what up 0.5 0.6? Well fortunately the 2023 AHA ACC guidelines seems to feel that these two doses are both considered low dose and and say both are fine for secondary prevention in patients with ascvd.

[Austin]

Surprise, surprise. More drug company shenanigans.

[Emily]

Always. Send us your thoughts by emailing [e-mail].

[Austin]

Follow on Instagram AFP Journal. Please subscribe and rate us wherever you get your podcasts.

[Podcast Announcer]

Escuchanos en Espanol A Revista Medica A fap.

[Emily]

Our podcast team is Jake Anderson, Puneet.

[Austin]

Bharot, Steve Brown, Justin Chetiak, Sarah Coles.

[Emily]

Austin Cotter, Rachel Dunn, Emily Eisenberg, Alaina, Kelly Chisholm Okuwagu and Kari Stauss. 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.

[Steve]

This podcast is brought to you by.

[Podcast Announcer]

The residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine residency programs.

[Austin]

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