Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach the discussion regarding loss of muscle mass with GLP-1 agonists in your non-geriatric population where the negative repercussions may not be as obvious?
We start by having the discussion PRIOR to starting the medication. We educate that this is not a GLP-1 phenomenon but a result of weight loss. We reinforce this at every dose change and at every follow-up, emphasizing protein and strength training. We use a body composition analysis scale to help p...
When do you consider starting medications such as metformin or a GLP-1 RA for the purpose of DM prevention in patients whose A1c% is not in the diagnostic range but demonstrates progressive weight gain/metabolic dysfunction?
Realistically, starting a GLP-1 is almost entirely dependent on whether insurance covers the medication or not. Given that Medicare/Medicaid covers the medicine for diabetes, OSA, cardiovascular disease, or MASH, I find it is often difficult to get it covered solely for obesity unless they have cert...
How do you counsel patients who are considering stopping a GLP-1 agonist after achieving their weight loss goal, now that long-term maintenance data suggest most will regain a substantial portion of their weight within a year of discontinuation?
Great question! I actually incorporate this knowledge into my initial medication counseling to see whether patients are comfortable being on this medication chronically. I let almost everyone know that coming off the medication will likely lead to significant weight gain, and that comes with signifi...
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
Do you routinely hold SGLT2 inhibitors prescribed for CHF or CKD in acutely ill patients upon admission to the hospital?
Thanks for this great question. The use of SGLT2 inhibitors in the hospital has been increasing dramatically, given their great effects on CKD and CHF for both diabetic and non-diabetic patients. There are simple direct contraindications for using SGLT2s, which would include patients with ketosis in...
Do you routinely hold SGLT2 inhibitors prescribed for CHF or CKD in acutely ill patients upon admission to the hospital?
Thanks for this great question. The use of SGLT2 inhibitors in the hospital has been increasing dramatically, given their great effects on CKD and CHF for both diabetic and non-diabetic patients. There are simple direct contraindications for using SGLT2s, which would include patients with ketosis in...
For elderly patients (i.e. older than 80) with only one documented episode of paroxysmal atrial fibrillation following a stress event (such as acute illness/steroid administration) and a CHADsVASc score greater than 1, how would you counsel them on the risks/benefits of anticoagulation and subsequent monitoring for afib recurrence?
If it were an isolated event, I would advocate continued monitoring for recurrence before starting an anticoagulant with the understanding that the risk of AF recurrence is relatively high.
Do you utilize the bronchiectasis severity index (BSI) in your approach to managing non-CF bronchiectasis?
I calculate it for academic reasons in my bronchiectasis clinic. It perhaps affects the frequency of visits in the clinic. Otherwise, not much practical application. I respond to daily cough and secretion management with stepping up airway clearance, and to frequency bronchiectasis exacerbations wit...
What alternative, low-effort airway clearance strategies do you use in frail neuromuscular patients who are unable to tolerate or fail manual chest physiotherapy (e.g., oscillating PEP devices, high-frequency chest wall oscillation vests, or mechanical insufflation-exsufflation/cough assist)?
Airway clearance is key to quality of life and prolonged survival in frail NMD patients, sometimes adding decades, depending on the particular NMD and other factors (luck and prayers don't hurt). Most tolerate manual techniques (i.e., quad coughing) reasonably well, so I wouldn't wait for them to no...
How do you characterize pleural effusions on POCUS between trace, small, moderate, and large?
Assuming the effusion is free-flowing and not loculated, there are a few equations out there that can help quantify pleural effusion volume based on whether the patient is supine at max inspiration, supine at end-expiration, or sitting upright. In my hospitalist practice, I don't usually calculate b...