Episode 250 | March 2026 | Part 2 American Family Physician

Summary

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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

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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.

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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]

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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]

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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]

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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]

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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]

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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]

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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]

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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

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

Transcript

[A]

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] menopausecme.

[B]

Welcome to the American Family Physician podcast for part two of the March 2026 issue. I'm Jake.

[C]

I'm Chiso.

[D]

And I'm Rachel.

[B]

And we are residents and faculty, mostly residents, of the University of Arizona College of Medicine, Phoenix Family Medicine Residency programs. Today on the podcast we'll talk about qPad test for A1C multiple myeloma, SGLT2 receptor inhibitors, croup sustained Release Naltrexone and Flu Score VAX Risk Predictor Tool.

[D]

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.

[B]

We're on a Mission Delivering the Best from American Family Physician On a mission Delivering the Best from American Family Physician first up, we have a diagnostic test QPAD test System to measure A1C and this comes from physician and pharmacist team of Drs. Miller and Whaley from Penn State Health in Hershey, Pennsylvania. This QPAD test system is a novel at home method for measuring A1C using menstrual blood. Yeah, you heard that right. Menstrual blood.

[C]

The QPAD is FDA approved and designed for adults 18 and older with diabetes. Patients collect menstrual blood on a specialized pad, mail it to a lab and receive an A1C result. It's marketed as a non invasive, accessible alternative to traditional venous testing.

[D]

In terms of accuracy, three small prospective observational studies compared paired venous and menstrual A1C samples. They found no statistically significant differences, which is promising, but we should note the limitations. Sample sizes were small, venous blood was used as the reference standard and the studies were conducted by the developers of the technology.

[B]

So while concordance looks good on paper, we don't yet have large scale independent validation. There's also concern about variable accuracy at higher A1C loop ranges.

[C]

An upside to this accessibility. This could reduce barriers related to transportation, insurance or limited clinic availability. It can be purchased directly from the manufacturer website for just under $50 per kit and doesn't require a prescription. However, it's not covered by insurance, Medicare or Medicaid.

[D]

Important caveats are it should not be used to diagnose or screen for diabetes. It's limited to menstruating individuals, and it's not recommended in pregnancy. Here, hemolytic conditions, significant blood loss or for patients requiring daily glucose monitoring.

[B]

There's also the broader issue of clinical guidance. Because it's sold directly to consumers, patients may obtain results without provider input on interpretation or next steps for management.

[C]

Bottom LINE the QPAD represents an innovative approach to A1C monitoring and may improve access to four select patients. But until larger independent studies confirm reliability across diverse populations, it should not replace standard Venus A1 testing for diagnosis or routine monitoring.

[B]

Next up, we have a main topic, multiple myeloma diagnosis and treatment, and it comes to us from Drs. Hughes, Shreve and Bloecker from Uniformed Services University of the Health Sciences.

[D]

Okay, so multiple myeloma is a malignancy of plasma cells, which are those antibody producing cells in our bone marrow. What makes it clinically distinctive is that these malignant cells overproduce monoclonal proteins. The classic presentation can be remembered using the mnemonic CRAB hypercalcemia, renal failure, anemia and bone lesions. But here's the catch about one third of patients are actually asymptomatic at diagnosis.

[C]

Asymptomatic patients often present with bone pain that's about 58% of cases, or fatigue in about 32%. Other symptoms could include pathologic fracture, recurrent infections and rarely peripheral neuropathy or manifestations of hyperviscosity such as stroke, retinal hemorrhage, or cvas.

[B]

So when you suspect myeloma, what's the diagnostic game plan?

[D]

Initial workup includes a CBC with peripheral smear, a CMP TSH urinalysis, as well as serum and urine protein electrophoresis with immunofixation and imaging should initially consist of plain radiographs of symptomatic bony sites.

[C]

If these initial tests are abnormal and multiple myeloma is suspected, you should refer to Oncology for additional labs, such as a serum beta 2 microglobulin lactate dehydrogenase, serum free light chain assay, bone marrow studies and skeletal survey with MRI or PET CT.

[B]

The diagnosis requires at least 10% clonal plasma cells in the bone marrow plus evidence of end organ damage, the CRAB criteria, or specific biomarkers like a free light chain ratio of 100 or greater.

[D]

For staging, the Revised International Staging System and Mayo Clinic's risk stratification are used, which incorporate beta 2 microglobulin, albumin, LDH, and high risk cytogenetics. This helps predict prognosis and guide treatment intensity. The good news? Five year survival has doubled from 30% in 1990 to 61% by 2020.

[B]

So let's talk treatment.

[C]

Treatment hinges on transplant eligibility for autologous stem cell transplant eligible patients. The preferred regimen is now a four drug combination. After three to six months, patients proceed to autologous stem cell transplant followed by maintenance therapy which can continue for years.

[D]

Don't forget that prior to starting treatments, patients should undergo screening for hiv, hepatitis B and hepatitis C. In addition to

[B]

transplant, there are a number of therapies to target complications of multiple myeloma.

[C]

All patients should receive bone targeting therapy, either bisphosphonates like soledronic acid or denosumab for at least two years to prevent skeletal related events. Venous thromboembolism prophylaxis is also essential. Aspirin is used for lower risk patients, but higher risk patients need anticoagulation with low molecular weight heparin or doacs. The IMPEDEVTE scoring system is a validated tool for risk stratification and is available on MD Calc.

[B]

Infection prevention is also huge. These patients are immunocompromised from both the disease and the treatment.

[D]

Fluconazole is recommended when absolute neutrophil count

[C]

is less than 500 and lastly, vaccinations are critical. Pneumococcal influenza, Covid and recombinant zoster vaccines are all recommended with timing coordinated around treatment. Some vaccines are recommended for repeat administration such as H flu, tdap, hepatitis A and B, meningococcus, polio and hpv. It's also important for close contacts to be up to date on vaccines.

[B]

Moving right along, we have an FPIN clinical inquiries and it comes to us from Dr. Swanson Lucier, Jean Baptiste Neher, all from Valley Family medicine in Renton, Washington.

[D]

The clinical question here is do sodium glucose transporter 2 or SGLT2 inhibitors increase the risk of urogenital infections?

[C]

This is good. I counsel patients on this risk based on original guidance with these meds. But I'm curious to hear what the updated evidence says and fortunately we have

[D]

some strong data that includes a 2024 network meta analysis and 2023 systematic reviews. The short answer is yes, SGLT2 inhibitors do increase the risk for urogenital infections, but let's dive a little deeper.

[B]

All right, so in looking at studies of patients with type 2 diabetes, mean ages ranging from 22 to 81, they found a number needed to harm between 16 and 31 for SGLT2 inhibitors causing genital infections when compared to placebo or standard care. This means that for every 16 to 31 patients you treat with an SGLT inhibitor compared to placebo, they're going to develop a urogenital infection.

[C]

They also found that women were at a much higher risk, along with those with a BMI of 30 or greater and those using SGLT2 inhibitor therapy for six months or longer.

[B]

In specifically looking at urinary tract infections, they found a number needed to harm of 16 for SGLT2 therapy. For UTIs, there was not an apparent difference in risk based on sex overall, and the risk does not appear to be different based on whether the patients had diabetes or not.

[C]

And looking specifically at Fournier's gangrene, the dreaded emergent complication, a 2019 study looked at men with type 2 diabetes and compared about 138,000 taking SGLT2 inhibitors to about 380,000 taking DPP4 inhibitors and found a slight but non significant increase in hospitalizations for 48 gangrene in the SGLT2 group. They concluded that this should not influence prescribing decision.

[B]

All right, bottom line it for us, Rachel.

[D]

Okay, so 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. There is also a small increase in the risk of UTIs, but these medications do not appear to increase the risk of Fournier gangrene.

[C]

We'll be right back.

[A]

The AFP podcast is brought to you by the American Academy of Family Physicians and by the AAFP audio app. Listen to clinical and management content from American Family Physician and FPM anywhere and earn CME credits on your schedule. Download now and enhance your family medicine expertise. Download today on the App Store or Google Play Store.

[B]

We have another main topic, Croup Rapid Evidence Review, and it comes to us from doctors Cook, Conway and Griffin from the University of Tennessee Health Science center in Chattanooga, Tennessee.

[C]

Croup is most common in children 6 months to 3 years of age, with peak incidence in the second year of life. It's typically viral, with parainfluenza virus remaining as the most common pathogen, though other respiratory viruses can be responsible.

[D]

Clinically, we're looking at the classic triad barking cough, inspiratory stridor and a hoarseness often preceded by non specific upper respiratory symptoms. An Australian case series actually found that cough had a positive likelihood ratio of 40 and a negative likelihood ratio of 0.02, which is pretty impressive.

[B]

Yeah, that's helpful. It's important to note that severity assessment guides management. The key points here are that mild disease presents with Barki cough but no stridor at rest. Moderate to severe disease includes stridor at rest, retractions, agitation or hypoxia. The Wesley Croup score can standardize that assessment, though in practice many of us rely on overall clinical impression.

[C]

Let's talk treatment. If there's one thing to remember, it's that you can treat with corticosteroids for all severities of croup. A single dose of oral dexamethasone improves symptoms, reduces return visits. The standard dose remains 0.6 milligrams per kilogram, though lower doses may be effective in mild cases. Prednisolone has also demonstrated effectiveness for moderate to severe croup.

[D]

Nebulized epinephrine is indicated. It provides rapid symptom improvement, typically within 30 minutes, but effects are transient. Children should be monitored for two to four hours after treatment to monitor for symptom recurrence. Both these treatment recommendations come as sort A recommendations.

[C]

The review also reinforces what not to do. Image and lab testing is typically not required for diagnosis unless presentation is atypical or standard treatment is ineffective. Imaging like neck radiographs showing the steeple sign quote unquote is unnecessary and hasn't actually been shown to correlate with clinical severity.

[B]

Really?

[C]

Further imaging and testing should be reserved for situations where diagnosis is unclear or alternative pathology is suspected.

[D]

And that brings us to red flags. We should consider alternative diagnosis in children with drooling dysphagia, toxic appearance, abrupt onset without viral prodrome or poor response to standard therapy. Epiglottitis, bacterial tracheitis, foreign body aspiration and retropharyngeal abscesses remain critical considerations.

[B]

From a systems perspective, the evidence supports outpatient management. For most cases, croup is typically self limited, resolving within three to seven days. Clear discharge instructions are essential, though, particularly with guidance on when to return, especially watching for symptoms like worsening stridor, increased work of breathing or poor hydration.

[D]

So to summarize diagnose clinically, give dexamethasone for all severities. Add nebulized epinephrine for moderate to severe cases. Observe appropriately and avoid unnecessary testing or imaging.

[C]

I could not have said it better.

[B]

Next up, we have a medicine by the numbers sustained release naltrexone for opioid dependence and it comes to us from doctors Stanton, Lujan and Valerio from Scott Air Force Base in Illinois.

[C]

So we know that opioid use disorder continues to be a public health crisis. This medicine by the numbers looks at a sustained release version of naltrexone brand named Vivitrol as a tool to treat oud.

[D]

Naltrexone is an opiate antagonist so it works by binding opioid receptors to block the euphoric effects and potentially prevent return to use. The sustained release version is delivered via implant or injection with redosing between two weeks and nine months depending on formulation. However, currently the only FDA approved formulation is dosed every four weeks.

[B]

That is exciting because it may remove some treatment barriers that the daily oral dosing presents.

[C]

To evaluate its use for OUD, the authors identified a 2025 Cochrane review across 22 randomized controlled trials. Sustained release naltrexone was compared with multiple different interventions, opioid agonists like methadone, oral naltrexone, placebo and treatment as usual.

[D]

Compared with treatment as usual, they found reduced in treatment, illicit opioid use and fewer serious adverse events with sustained release naltrexone. And though based on very low certainty evidence, sustained release naltrexone is also associated with better treatment retention compared with placebo.

[C]

Unfortunately, there are quite a few limitations to this data. Vulnerable populations like pregnant persons and individuals with significant mental health disorders were excluded and the trials were often underpowered, industry funded and showed inconsistent results.

[D]

So this Medicine by the Numbers team concludes that overall the benefits are unclear, assigning a color rating of yellow for the use of sustained release naltrexone for opioid use disorder. Larger, higher quality studies across diverse populations are needed.

[B]

We're going to wrap this episode up with a poem and it's about the flu score vax. It comes to us from Dr. Slauson.

[D]

Our clinical question is Fluscorvax risk scoring tool accurate for assessing the risk of influenza in adult outpatients with a chief symptom of acute cough?

[C]

Flu Score VAX is an updated risk score that incorporates vaccination status to predict influenza in adults presenting with acute cough. It accurately identifies low risk patients who don't need testing or treatment.

[B]

And the numbers are compelling. In the validation study, 61% of patients were classified as low risk, meaning they scored between negative five to zero points and only 7% of those actually had influenza. That's a game changer for reducing unnecessary testing and antivirals.

[D]

So what goes into this score?

[C]

6 simple variables Subjective fever, interference with usual activities, headache, wheeze, phlegm and flu vaccine status. The score ranges from negative five to six points. It was derived from over 1500 European patients invalidated in a US population with influenza prevalence around 15% in both cohorts,

[B]

low risk patients, those scoring zero or below probably don't need point of care testing or oseltamivir that saves resources and reduces unnecessary medication exposure.

[D]

Are there any limitations we should mention?

[C]

It's specifically for adults with acute cough during flu season presenting to outpatient settings. It's not designed for hospitalized patients or those with severe illness requiring immediate intervention.

[B]

So the bottom line? Fluscorvax gives us evidence based confidence to reassure low risk patients and focus our testing and treatment on those who will actually benefit.

[A]

Send us your thoughts by emailing us

[B]

at AFPPodcastAFP.org follow us on Instagram at afpjournal.

[C]

Please subscribe and rate us more wherever

[D]

you get your podcasts. Escucanos en Espanol A Revista Medica a

[C]

FA Pay Our podcast team is Jake

[A]

Anderson, Puneet Bharot, Steve Brown, Justin Chetiak,

[B]

Sarah Coles, Austin Cotter, Rachel Dunn, Emily Eisenberg, Elena Kelly, Chisa Mokouagu and Kari Staus.

[C]

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.

[B]

This podcast is brought to you by the residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine Residency Programs.

[D]

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