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)

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.

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.

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]

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]

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]

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]

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]

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]

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 |

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