🗞️ TLDR Primary Care - Rapid Fire Guidelines (#086)

In this issue:

⚡️Rapid guideline summaries for:

🪨 Nephrolithiasis

🦟 Malaria

⚖️ Lichen Sclerosis

💤 Narcolepsy

🎯 Lyme Disease

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 easier to understand.

🧠 Ask Pathway AI:

1. What are the signs and symptoms of lichen sclerosis?
2. Who should be given malaria prophylaxis and what medication options are there?
3. Who should be empirically treated for lyme disease after a tick bite?

🪨 Nephrolithiasis - from the European Association of Urology (EAU 2024), the American College of Radiology (ACR 2023), and the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), among others:

• Obtain serum chemistries, including creatinine, uric acid, (ionized) calcium, sodium, and potassium, as well as blood cell count and CRP in patients with nephrolithiasis. (A)
• Obtain a coagulation test (PTT and INR) if intervention is likely or planned. (A)
• Obtain dipstick test of spot urine sample for erythrocytes, leukocytes, nitrites, approximate urine pH, urine microscopy, and/or culture in patients with nephrolithiasis. (B)
• Obtain ultrasound in patients with a suspected kidney stone. Obtain unenhanced helical CT to determine the HUs to provide information about the possible stone composition. (A)
• Obtain non-contrast CT to confirm stone diagnosis in patients with acute flank pain following initial ultrasound assessment. (A)
• Obtain stone analysis in first-time formers using a valid procedure (X-ray diffraction or infrared spectroscopy). (A)
• Offer medical expulsive therapy with α-blockers as a treatment option in patients with (distal) ureteral stones > 5 mm. (A)
• Advise maintaining a generous fluid intake, preferably water, allowing for a 24-hour urine volume > 2.5 L, for the prevention of recurrence. (A)
• Offer percutaneous nephrolithotomy as first-line therapy in patients with larger stones > 2 cm. (A)

🦟 Malaria - from the National Institutes of Health (NIH/CDC/HIVMA/IDSA 2023; 2013), the World Health Organization (WHO 2022), and the British Society for Haematology (BSH 2022), among others:

• Administer any of the following artemisinin-based combination therapies for 3 days for the treatment of adult patients with uncomplicated P. falciparum malaria:
  • artemether-lumefantrine
  • artesunate-amodiaquine
  • artesunate-mefloquine
  • dihydroartemisinin-piperaquine
  • artesunate plus sulfadoxine-pyrimethamine
  • Artesunate-pyronaridine. (A)
• Administer a single dose of 0.25 mg/kg body weight primaquine with artemisinin-based combination therapy in patients with P. falciparum malaria (except pregnant patients and patients breastfeeding infants aged < 6 months) to reduce transmission in low-transmission areas. Do not obtain G6PD testing. (B)
• Administer a 14-day course of primaquine for the treatment of P. vivax or P. ovale malaria in adult patients (except pregnant patients, patients breastfeeding infants aged < 6 months, patients breastfeeding older infants unless they are known not to be G6PD deficient, and patients with G6PD deficiency) to prevent relapse in all transmission settings. (A)
• Do not use topical repellents for the prevention and control of malaria at the community level in areas with ongoing malaria transmission. (D)
• Obtain annual monitoring for retinopathy in all patients receiving hydroxychloroquine for > 5 years or chloroquine for > 1 year. (B)

⚖️ Lichen Sclerosus - from the American College of Obstetricians and Gynecologists (ACOG 2020), the British Gynaecological Cancer Society (BGCS 2020), and the British Association of Dermatologists (BAD 2018), among others:

• Perform vulvar biopsy of visible lesions in any of the following circumstances:
  • atypical lesions (such as new pigmentation, indurated, affixed to underlying tissue, bleeding, or ulcerated)
  • concern for malignancy
  • immunocompromised conditions (including HIV)
  • diagnostic uncertainty
  • lesions not responding to standard therapy
  • disease worsening during treatment. (B)
• Offer medium-potency or high-potency topical corticosteroid ointment for the initial treatment of patients with lichen sclerosis (LS). (A)
• Offer long-term, individualized topical corticosteroids to maintain normality of skin color and texture and to prevent scarring in patients with LS. (B)
• Consider offering topical calcineurin inhibitors (such as tacrolimus or pimecrolimus) in patients with confirmed LS not responding to topical or intralesional corticosteroids or in patients at risk of skin atrophy. (C)
• There is insufficient evidence to support the use of topical hormone therapy (progesterone or testosterone) in patients with vulvar LS. (I)

💤 Narcolepsy - from the British Thoracic Society (BTS 2023), the American Academy of Sleep Medicine (AASM 2021), and the European Academy of Neurology (EAN 2021):

• Offer the following medications for the treatment of excessive daytime sleepiness in adult patients with narcolepsy:
  • armodafinil
  • pitolisant
  • sodium oxybate
  • solriamfetol. (A)
• Offer the following medications for the treatment of cataplexy in adult patients with narcolepsy:
  • pitolisant
  • sodium oxybate. (A)
• Consider offering baclofen as second-line therapy for the treatment of disturbed nighttime sleep in patients with narcolepsy. (C)
• Offer planned daytime naps to improve immediate subjective and objective sleepiness both in drug-naïve patients and in patients taking stimulant medication, at any age. (B)

🎯 Lyme Disease - from the Infectious Diseases Society of America (IDSA/AAN/ACR 2021), the Wilderness Medical Society (WMS 2021), and the American College of Cardiology (ACC/AHA/HRS 2019):

• Do not test asymptomatic patients for exposure to Borrelia burgdorferi following an Ixodes species tick bite. (D)
• Obtain serum antibody testing rather than PCR or culture of blood or synovial fluid/tissue when assessing patients with possible Lyme arthritis. (B)
• Complete a 10-day course of doxycycline or a 14-day course of amoxicillin or cefuroxime rather than longer treatment courses in patients with erythema migrans. (B)
• Offer oral antibiotic therapy for 28 days to patients with Lyme arthritis. (B)
• Offer IV ceftriaxone, cefotaxime, penicillin G, or oral doxycycline rather than other antimicrobials to patients with Lyme disease-associated meningitis, cranial neuropathy, radiculoneuropathy, or with other PNS manifestations. (B)
• Promptly remove attached ticks by mechanical means using a clean fine-tipped tweezer (or a comparable device) inserted between the tick body and the skin. (B)
• Do not burn an attached tick (with a match or other heat device) or apply noxious chemicals or petroleum products to coax its detachment. (D)

🎉 Something Fun

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