AFP: American Family Physician Podcast

Episode 250 | March 2026 (Part 2)
Released: March 30, 2026
Host Location: University of Arizona College of Medicine–Phoenix Family Medicine Residency Programs

Episode Overview

This episode features faculty and residents discussing key clinical updates and evidence-based recommendations from the March 2026 issue of American Family Physician. Topics include at-home A1C testing with the QPAD, updates on multiple myeloma management, SGLT2 inhibitor risks, rapid review of croup, sustained-release naltrexone for opioid dependence, and the Flu Score VAX risk tool.

1. QPAD Test for A1C: At-Home Monitoring Using Menstrual Blood

[01:14 – 03:30]

• Innovation: The QPAD test is FDA-approved as an at-home method to measure A1C using menstrual blood, targeted at adults 18+ with diabetes.
• How It Works:
  • Collect menstrual blood on a special pad, mail to lab, receive result ($50/kit, no insurance coverage).
• Evidence:
  • Three small observational studies found strong concordance with traditional venous A1C, but all were industry-sponsored with small sample sizes.
  • "No statistically significant differences, which is promising, but we should note the limitations." – Rachel [02:10]
• Limitations:
  • Not for diagnosis/screening of diabetes, only for menstruating individuals, not for pregnancy, hemolytic conditions, significant blood loss, or patients needing daily glucose monitoring.
  • No large-scale independent validation; reliability at higher A1C ranges is uncertain.
• Cautions:
  • Direct-to-consumer with no provider oversight; patients may misinterpret results.
• Bottom Line:
  • “Until larger independent studies confirm reliability across diverse populations, it should not replace standard venous A1C testing for diagnosis or routine monitoring.” – Chiso [03:30]

2. Multiple Myeloma: Diagnosis and Management

[03:49 – 07:43]

• Definition & Presentation:
  • Malignancy of plasma cells in bone marrow, characterized by overproduction of monoclonal proteins.
  • Classic CRAB features: hyperCalcemia, Renal failure, Anemia, Bone lesions.
  • Up to 1/3 asymptomatic at diagnosis; often presents with bone pain (58%) or fatigue (32%).
• Workup:
  • CBC, CMP, TSH, urinalysis, serum/urine protein electrophoresis, imaging (start with x-rays).
  • Suspected cases referred for advanced labs and imaging (serum β2-microglobulin, LDH, free light chain assay, marrow, skeletal survey, MRI, PET/CT).
• Diagnosis:
  • ≥10% clonal plasma cells + end organ damage or specific biomarkers (e.g., free light chain ratio ≥100).
• Staging:
  • Revised International Staging System integrates β2-microglobulin, albumin, LDH, cytogenetics.
  • 5-year survival improved from 30% in 1990 to 61% in 2020.
• Treatment:
  • Transplant eligibility key (autologous SCT after 3–6 months of 4-drug therapy, maintenance up to several years).
  • Screen for HIV, Hep B/C before therapy.
  • Bone protection (bisphosphonates/denosumab), VTE prophylaxis (Aspirin or anticoagulation based on risk), infection prevention (fluconazole if ANC < 500).
  • Vaccinations are critical (pneumococcal, flu, COVID, shingles, and more; close contacts should also be vaccinated).
• Quote:
  • "The good news? Five year survival has doubled from 30% in 1990 to 61% by 2020." – Jake [05:43]

3. SGLT2 Inhibitors and Urogenital Infections

[07:43 – 10:17]

• Clinical Question: Do SGLT2 inhibitors increase risk for urogenital infections?
• Evidence:
  • 2024 meta-analysis and 2023 reviews confirm increased risk.
  • Number needed to harm: 16–31 for genital infections; NNH of 16 for UTIs.
  • Higher risk: women, BMI ≥30, >6 months use.
  • Little/no increased Fournier’s gangrene risk.
• Quote:
  • "Physicians should counsel adults treated with SGLT2 inhibitors about an increased risk of urogenital infections. Groups at highest risk include women, patients with obesity, and patients treated for six months or longer." – Rachel [09:54]

4. Rapid Evidence Review: Croup

[10:41 – 13:45]

• Presentation:
  • Most common in ages 6 months–3 yrs; presents with barking cough, inspiratory stridor, hoarseness.
  • Cough is highly predictive (LR+ 40, LR– 0.02).
• Severity:
  • Mild: cough only; Moderate–Severe: stridor at rest, retractions, hypoxia.
  • Wesley Croup Score can be used, but clinical impression prevails.
• Treatment:
  • Steroids for all (single dose dexamethasone 0.6mg/kg; lower dose may suffice for mild; prednisolone also effective).
  • Nebulized epinephrine for moderate-severe (fast effect but transient; monitor 2–4 hrs).
  • Avoid routine imaging/labs unless atypical/prolonged course.
• Red Flags:
  • Consider alternate diagnoses if drooling, dysphagia, toxic appearance, sudden onset w/o prodrome or poor response to therapy ("Epiglottitis, bacterial tracheitis, foreign body aspiration, and retropharyngeal abscesses remain critical considerations." – Rachel [13:02])
• Disposition:
  • Most managed outpatient, self-limited in 3–7 days; give clear return precautions.
• Summary:
  • "Diagnose clinically, give dexamethasone for all severities. Add nebulized epinephrine for moderate to severe cases. Observe appropriately and avoid unnecessary testing or imaging." – Rachel [13:45]

5. Medicine by the Numbers: Sustained-Release Naltrexone for Opioid Use Disorder

[13:59 – 15:43]

• Background:
  • Sustained-release naltrexone (Vivitrol) is FDA-approved as a monthly injection for OUD, blocks opioid receptors, may improve adherence vs. daily dosing.
• Evidence:
  • 2025 Cochrane review of 22 RCTs: reduced illicit opioid use and adverse events vs. usual care, possibly better retention than placebo, but "very low certainty evidence."
  • Limitations: Vulnerable populations excluded, inconsistent results, industry funding, underpowered studies.
• Bottom Line:
  • Benefits are unclear; "yellow" evidence rating; more high-quality studies needed.
• Quote:
  • “The benefits are unclear, assigning a color rating of yellow for the use of sustained release naltrexone for opioid use disorder.” – Rachel [15:43]

6. POEM: Flu Score VAX – Predicting Influenza Risk in Outpatients

[16:00 – 17:58]

• Tool:
  • Flu Score VAX integrates vaccine status with six clinical variables for adults with acute cough during flu season.
  • Six variables: subjective fever, activity interference, headache, wheeze, phlegm, flu vaccination status.
  • Range: –5 to +6 points.
• Performance:
  • Validated in 1500+ European and US patients (flu prevalence ~15%).
  • Score ≤0: 61% are low risk—only 7% actually had influenza (large reduction in unnecessary testing/antivirals).
• Quote:
  • “In the validation study, 61% of patients were classified as low risk...only 7% of those actually had influenza. That's a game changer for reducing unnecessary testing and antivirals.” – Jake [16:32]
• Limitations:
  • Outpatients only, not for hospitalized/severely ill.
• Summary:
  • "Fluscorvax gives us evidence based confidence to reassure low risk patients and focus our testing and treatment on those who will actually benefit." – Jake [17:42]

Notable Quotes & Memorable Moments

• QPAD Discussion:
  • "Yeah, you heard that right. Menstrual blood." – Chiso [01:53]
• On Croup Diagnostic Testing:
  • "Imaging like neck radiographs showing the ‘steeple sign’ is unnecessary and hasn't actually been shown to correlate with clinical severity." – Chiso [12:33]
• On Multiple Myeloma Progress:
  • "The good news? Five year survival has doubled from 30% in 1990 to 61% by 2020." – Jake [05:43]

Timestamps Key Segments

• QPAD Test for A1C: 01:14 – 03:30
• Multiple Myeloma: 03:49 – 07:43
• SGLT2 Inhibitor Risks: 07:43 – 10:17
• Croup Rapid Evidence Review: 10:41 – 13:45
• Sustained-Release Naltrexone: 13:59 – 15:43
• Flu Score VAX: 16:00 – 17:58

Summary crafted to reflect the original conversational, explanatory, and collegial tone of the podcast participants.