🗞️ TLDR Primary Care - Rapid Fire Guidelines (#027)

In This Issue:

⚡️Rapid guideline summaries for:

🔵 Diabetes mellitus type 2

🩸 Giant cell arteritis

💊 Vitamins, minerals, and dietary supplements

🥐 Celiac disease

🦴 Postmenopausal osteoporosis

🗞  Rapid Fire: Guideline Summaries

Do-not-miss guidelines, broken down for you

You’ll find some of the newest guidelines relevant to Primary Care below, along with a few key takeaways from each one of them.

Some of these guidelines are dense – but don’t worry, over at Pathway they’re all neatly summarized and broken down into digestible chunks to make them easy to parse.

🔵 Diabetes mellitus type 2 - from the American Diabetes Association (2023), the Endocrine Society (2022), and KDIGO (2022) among others:

• Consider testing for prediabetes and/or T2DM in all asymptomatic adults with overweight or obesity (BMI > 25 kg/m2) having 1 of the following risk factors: (C)
  • First-degree relative with diabetes
  • High-risk ethnicity (African American, Latino, Native American, Asian American, Pacific Islander)
  • History of cardiovascular disease
  • Patients with hypertension, PCOS, physical inactivity, or other clinical conditions associated with insulin resistance
• Begin screening at age 35 in all other patients. (B)
• Initiate SGLT-2 inhibitors or GLP-1 receptor agonists with demonstrated cardiovascular disease benefits as part of comprehensive cardiovascular risk reduction and/or glucose-lowering regimens in patients with T2DM and established ASCVD or established chronic kidney disease. (A)
• Do not use ACEIs or ARBs for the primary prevention of CKD in patients with diabetes and normal BP, normal urinary albumin-to-creatinine ratio (< 30 mg/g creatinine), and normal estimated GFR. (D)
• Offer metabolic surgery for the treatment of T2DM in screened surgical candidates BMI > 40 kg/m2 (BMI > 37.5 kg/m2 in Asian Americans) who have not achieved durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods. (A)

🩸 Giant cell arteritis - from the American Heart Association/American College of Cardiology (2022), the Vasculitis Foundation/American College of Radiology (2021), and the American Stroke Association (2021) among others:

• Diagnose giant cell arteritis (GCA) based on the following criteria, classifying patients with a score of > 6 points as having GCA:
  • Age > 50 years is required for diagnosis
  • +5 points: Positive temporal artery biopsy or temporal artery halo sign on ultrasound
  • +3 points each: erythrocyte sedimentation rate > 50 mm/hour OR C-reactive protein > 10 mg/liter OR sudden visual loss
  • +2 points each: Morning stiffness in shoulders or neck, jaw or tongue claudication, new temporal headache, scalp tenderness, temporal artery abnormality on vascular examination, bilateral axillary artery involvement on imaging, or positive FDG-PET activity throughout the aorta
• Obtain prompt evaluation of the entire aorta and branch vessels with MRI or CT (with or without 18F-FDG-PET) in patients with large vessel vasculitis. (B)
• Initiate high-dose corticosteroids as initial medical therapy in patients with active GCA. (B)
• Consider initiating tocilizumab in addition to oral corticosteroids in patients with newly diagnosed GCA. (B)
• Avoid using statins specifically for the treatment of patients with newly diagnosed GCA. (D)
• Consider obtaining annual surveillance imaging with CT, MRI, or 18F-FDG-PET in patients with GCA and aortic involvement who are in remission. (C)

💊 Vitamins, minerals, and dietary supplements - from the USPSTF (2022), the WHO (2022), and the American Association for the Study of Liver Diseases (2022) among others:

• Do not use vitamin D supplements for the prevention of falls in community-dwelling adults > 65 years of age. (D)
• Do not use vitamin E or 𝛽-carotene supplements for the prevention of cardiovascular disease or cancer. (D)
• Do not use coenzyme Q10 as a neuroprotective therapy in patients with Parkinson’s disease. (D)
• Initiate two adult multivitamins plus minerals - each containing iron, folic acid, and thiamine - in a chewable form initially for 3-6 months, in all patients after Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy with minimal daily supplementation of: (B)
  • 1,200-1,500 mg of elemental calcium - in diet and as a citrated supplement in divided doses (B)
  • 3,000 IU of vitamin D - titrated to therapeutic 25-hydroxyvitamin D levels > 30 ng/mL (B)
  • Vitamin B12 titrated to serum B12 levels in the normal range (B)
  • 45-60 mg of elemental iron via multivitamins and supplements (I)

🥐 Celiac disease - from the American College of Gastroenterology (2023), the American Diabetes Association (2023), and the European Society of Gastrointestinal Endoscopy (2023) among others:

• Do not obtain mass screening for celiac disease in the community. (D)
• Obtain screening in asymptomatic first-degree family members of patients with celiac disease. (B)
• Obtain a DEXA scan at diagnosis of celiac disease in patients at high risk of osteoporosis such as: (B)
  • Malabsorption
  • A long delay in the diagnosis
  • Clinical presentations suggestive of bone disease
  • Patients aged 30-35 without any of the above risk factors 
• Consider offering vaccination to prevent pneumococcal disease in patients with celiac disease. (C)

🦴 Postmenopausal osteoporosis - from the American College of Physicians (2023), the American College of Obstetricians and Gynecologists (2022), and the Endocrine Society (2020) among others:

• Screen for osteoporosis in patients > 65 years old who are postmenopausal with bone mineral density testing, in order to prevent osteoporotic fractures. (A)
• Diagnose osteoporosis based on:
  • Presence of fragility fractures in the absence of other metabolic bone disorders, even with a normal bone mineral density. (B)
  • T-score of < -2.5 in the anteroposterior lumbar spine, femoral neck, total hip, or ⅓ radius, even in the absence of a prevalent fracture. (B)
• Initiate bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in postmenopausal patients with primary osteoporosis. (A)
• Initiate denosumab subcutaneously every 6 months as initial therapy in postmenopausal patients at increased risk of fracture (A)
• Consider discontinuing bisphosphonates to allow a drug holiday for low-to-moderate risk patients who are stable after 5 years of treatment with oral bisphosphonates or after 3 years of IV zoledronic acid. Consider continuing treatment for longer durations (up to 10 years in patients receiving oral bisphosphonates, or up to 6 years for IV zoledronic acid) in patients at high risk of fracture. (C)
• Consider obtaining DEXA testing every 1-3 years during pharmacological treatment for osteoporosis, depending on clinical circumstances, until bone density is stable. (C)

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