Gim board review conference 4 8-19

General Internal Medicine
Review
Joy Bucher, MD
April 8, 2019

© 2017 Virginia Mason
Credit
• Slides and topics adapted from:
2

Which of the following is true about the HPV
vaccine?
A. It has been linked with autism
B. It has been linked with increased sexual
activity in young adults
C. It is FDA approved up to age 45
D. It is CDC recommended up to age 45
3
From Pritish K. Tosh, MD, “Hot Topics in Infections Disease 2019”

HPV
• 80 million Americans have HPV
• >200 different serotypes
– 16 and 18 cause 70% of cervical cancer
– 6 and 11 cause 90% of genital warts
• >300,000 HPV-related cancers in the US
– Cervical, anal, penile and oropharyngeal
– 93% are vaccine-preventable
4

HPV vaccine
• Bivalent (16, 18) and Quadrivalent (6, 11,
16, 18) are no longer available in the US
• 9-valent only (6, 11, 16, 18, 31, 33, 45, 52,
58)
• Two doses given 6 to 12 months apart if
started before age 15
• Three doses at 2, 6, 12 months if started
after age 15
5

HPV Vaccine Recommendations
• Routine vaccination at age 11 or 12
• Range 9-26 (21 for men)
• In Oct 2018, the FDA approved use for up
to age 45
– Study in 3000 women age 27-45 found 9-
valent vaccine 88% effective in preventing
persistent infection, pre-cancer, cancer
related to HPV types covered in vaccine
• NOT recommended by the CDC, however
6

Which of the following is true about the HPV
vaccine?
A. It has been linked with autism
B. It has been linked with increased sexual
activity in young adults
C. It is FDA approved up to age 45
D. It is CDC recommended up to age 45
7
From Pritish K. Tosh, MD, “Hot Topics in Infections Disease 2019”

Combined hormonal contraception used
cyclically can help prevent menstrual
migraine.
A. TRUE
B. FALSE
8
Emily Leasure, MD, Cases in Contraception; Navigating the Options

Menstruation is the most common migraine
trigger, noted in up to 70% of female
patients with migraines.
9
Calhoun AH. Headache 2018.

Hormonal Migraines
• Triggered by a sharp decline in estrogen
concentration
• #1 cause of hormonal migraines is
menstrual migraines
• Other causes
– Scheduled withdrawal from estrogen-
containing products
– Unintentional withdrawal from missed doses
of estrogen-containing products
– Post-partum
10

Menstrual Migraines
• Are longer lasting, more severe and less
responsive to abortive treatment than
other migraines
• Decrease sensitivity of 5HT1 receptors –
target of triptans
11
Calhoun AH. Headache 2018.

• Minimizing premenstrual decline in
estrogen can prevent menstrual migraine
– Limit decline in estrogen to 10 mcg
• Options
– Continuous estrogen-progesterone
contraceptives
– Cyclic estrogen-progesterone with
supplemental estrogen
– Menstrually-targeted estrogen supplements
12

Combined hormonal contraception used
cyclically can help prevent menstrual
migraine.
A. TRUE
B. FALSE
13

32 year-old woman sees you for pre-op before
Roux-en-Y gastric bypass. What do you
recommend regarding post-op contraception?
A. Prevent pregnancy for 6 months; avoid all
forms of hormonal contraception
B. Prevent pregnancy for 6 months; avoid all oral
form of contraception
C. Prevent pregnancy for 2 years; avoid all forms
of hormonal contraception
D. Prevent pregnancy for 2 years; avoid all oral
forms of contraception.
14

Contraception after bariatric surgery
• Nearly half of patients undergoing bariatric
surgery in the US are reproductive-age
women
• ¼ are not provided perioperative
pregnancy or contraception counseling
– 41% who did receive counseling wished they
had more
• Up to 42% of women report unprotected
intercourse in the 1st postsurgical year
15
Mengesha BM. American Journal of Obstetrics & Gynecology. 2018.

• Bariatric surgery increases risk
– Prematurity
– NICU admission
– Small for gestational age
– Low Apgar
• Operation-to-birth intervals under 2 years
have higher risks compared to >4 years
16
Mechanick J. Obesity 2013; Menke MN. Obstetrics & Gynecology. 2017

• Guidelines cosponsored by American
Association of Clinical Endocrinologists,
Obesity Society, and American Society for
Metabolic & Bariatric Surgery in 2013:
– Women should avoid conception for 12-18
months after bariatric surgery
• Centers for Disease Control and
Prevention
– Elevated risk for 2 years
17

32 year-old woman sees you for pre-op before
Roux-en-Y gastric bypass. What do you
recommend regarding post-op contraception?
A. Prevent pregnancy for 6 months; avoid all
forms of hormonal contraception
B. Prevent pregnancy for 6 months; avoid all oral
form of contraception
C. Prevent pregnancy for 2 years; avoid all forms
of hormonal contraception
D. Prevent pregnancy for 2 years; avoid all oral
forms of contraception.
21

• 52 year-old man with history of liver transplant.
• Immunosuppressed on tacrolimus, mycophenolate
mofetil, and prednisone
• Recent initiation of diltiazem for afib
• Presents with 1 week of diarrhea and tremor
• BP 160/93, HR 95 irregular, tremor
• K 5.7, Cr 2.6 (from 1.0)
What is the most likely cause of his acute diarrhea, tremor,
hyperK, and AKI?
A. Acute gastrointestinal illness
B. Elevated mycophenolate mofetil level
C. Elevated tacrolimus level
D. Adverse effect of diltiazem 22

Tacrolimus: Calcineurin Inhibitor
• Main side effects
– Hyperkalemia
– Hypertension
– Post-transplant diabetes
– Neurotoxicity: tremor, peripheral neuropathy
cognitive impairment
– Renal impairment
• Trough monitoring is required
• MAJOR drug-drug interactions!
– CYP450
– Increased levels with diltiazem, azoles, macrolides
• Always check for interactions!
23

• 52 year-old man with history of liver transplant.
• Immunosuppressed on tacrolimus, mycophenolate
mofetil, and prednisone
• Recent initiation of diltiazem for afib
• Presents with 1 week of diarrhea and tremor
• BP 160/93, HR 95 irregular, tremor
• K 5.7, Cr 2.6 (from 1.0)
What is the most likely cause of his acute diarrhea, tremor,
hyperK, and AKI?
A. Acute gastrointestinal illness
B. Elevated mycophenolate mofetil level
C. Elevated tacrolimus level
D. Adverse effect of diltiazem 24

62 year-old man is a current smoker with 43 pack-
years. You advise smoking cessation and discuss risks
and benefits of lung cancer screening.
Which is correct?
A. Discovery of incurable cancer is more likely than
curable cancer.
B. Discovery of lung cancer is more likely than a
benign nodule(s).
C. If he elects not to have a CT, annual CXR is
recommended
D. The likelihood he will have a result with “no
abnormality” is >80%.
25
Craig Daniels, MD Lung cancer screening and pulmonary nodules

Lung Cancer Screening
A. Discovery of incurable cancer is more likely than curable
cancer.
CORRECT: Screening 1000 patients finds 18 incurable and 3 curable
cancers
B. Discovery of lung cancer is more likely than a benign
nodule(s).
Incorrect: 20 benign abnormalities are found for every 1 cancer
C. If he elects not to have a CT, annual CXR is recommended
Incorrect: Annual CXR is ineffective at reducing risk of lung cancer
death
D. The likelihood he will have a result with “no abnormality” is
>80%.
Incorrect: 40% of patients have abnormal results requiring f/u or tests
and 25% will fund a lung nodule; of these 1 in 25 is cancer
26
ABIM 2018: Choosing Wisely; www.choosingwisely.org/patient-resources

Lung Cancer Screening
• Smoking cessation saves more lives than
lung cancer screening
• NNS for 10 years to save 1 life is 320
• Shared-decision making is important
• Finding a benign nodule is likely and will
require f/u and or intervention
27

62 year-old man is a current smoker with 43 pack-
years. You advise smoking cessation and discuss risks
and benefits of lung cancer screening.
Which is correct?
A. Discovery of incurable cancer is more likely than
curable cancer.
B. Discovery of lung cancer is more likely than a
benign nodule(s).
C. If he elects not to have a CT, annual CXR is
recommended
D. The likelihood he will have a result with “no
abnormality” is >80%.
28
Craig Daniels, MD Lung cancer screening and pulmonary nodules

• 62-year old woman with non-ischemic cardiomyopathy
(EF 30%); NYHA class III symptoms.
– BP 95/60; HR 62; euvolemic
– Meds: furosemide 40 mg BID, Lisinopril 20 mg
daily, carvedilol 25 mg BID
– QRS 145 msec (RBBB); Afib
– Cr 1.6. K 4.6
What is the next step?
A. Refer to EP for cardiac resynchronization therapy
B. Start sacubatril/valsartan
C. Start spironolactone
D. Start ivabradine
29
Paul M. McKie, MD,
Optimizing Outpatient
Management of CHF

• Standard therapy for NYHA class I-IV CHF
– ACE-I or ARB
– Beta blocker
• NYHA II-IV
– Add aldosterone agonist
30
Reminder: NYHA classes in patients with CHF
I: No physical limitations
II: Slight limitations with ordinary activity
III: Marked limitations of activity but not at rest
IV: Limitations at rest

Standard therapy improves survival
31

• Despite clear guidelines and strong
evidence-base, most patients with CHF do
not attain guideline-recommended target
doses.
32Ouwerkerk et al. European Heart J. 2017, 1883-1890

Dose Matters
33
Ouwerkerk et al. European Heart J. 2017, 1883-1890

“Drugs don’t work in patients who don’t take
them.”
C. Everett Koop, MD
35

Aldosterone Antagonists
• Effective but underused: MORTALITY benefit
• NYHA II-IV
• NNT = 6 !!
• Start with spironolactone
• Switch to eplenerone if gynecomastia
• Risk: Hyperkalemia
– Cr <2.0 (women) and Cr <2.5 (men)
– Do not start if K >5; hold the course if <5.5
– Check at 3 days, 1 week, monthly x 3 months
then yearly 36
ACC/AHA 2013 Heart Failure Guidelines

Tips to Optimize Medical Therapy
• Go slow (marathon not a sprint); increase
in small increments every 1-2 weeks
• Tolerate asymptomatic hypotension
• Diuretic requirements may decrease with
positive remodeling
• Treat the patient not the creatinine
• Share the Seattle Heart Failure Model with
patients to promote buy-in for medical
therapy
39

• 62-year old woman with non-ischemic cardiomyopathy
(EF 30%); NYHA class III symptoms.
– BP 95/60; HR 62; euvolemic
– Meds: furosemide 40 mg BID, Lisinopril 20 mg
daily, carvedilol 25 mg BID
– QRS 145 msec (RBBB); Afib
– Cr 1.6. K 4.6
What is the next step?
A. Refer to EP for cardiac resynchronization therapy
B. Start sacubatril/valsartan
C. Start spironolactone
D. Start ivabradine
40
Paul M. McKie, MD,
Optimizing Outpatient
Management of CHF

A 62 year-old man with DM2 on metformin XR 500 mg
4 tabs after dinner has an A1c 7%. He has noticed the
whole pill in his stools on many occasions.
The best approach is to:
A. Reassure him that those are ghost pills and
continue current therapy
B. Change metformin from XR to immediate release
C. Change to metformin XR 2 tabs PO BID
D. Decrease dose to 2 tabs PO after dinner.
De41
Vinaya Simha, MD, MBBS, Practical Tips to Managing the Poorly controlled Diabetic

Ghost capsules
42

A 62 year-old man with DM2 on metformin XR 500 mg
4 tabs after dinner has an A1c 7%. He has noticed the
whole pill in his stools on many occasions.
The best approach is to:
A. Reassure him that those are ghost pills and
continue current therapy
B. Change metformin from XR to immediate release
C. Change to metformin XR 2 tabs PO BID
D. Decrease dose to 2 tabs PO after dinner.
De43
Vinaya Simha, MD, MBBS, Practical Tips to Managing the Poorly controlled Diabetic

• 82 year-old woman who 7 months ago:
– Progressive angina refractory to meds
– Drug eluting stent to right coronary artery
• Currently asymptomatic, EF and exam normal
• Aspirin 81 mg daily + clopidogrel 75 mg daily
• You do her pre-op consult prior to a left TKR
How do you manage timing of her surgery and the clopidogrel?
A. Stop clopidogrel now. No need to resume post-op.
B. Hold clopidogrel for surgery. Resume post-op to complete 12
months of therapy.
C. Delay surgery to complete 12 months of uninterrupted
clopidogrel.
44Michael Cullen, MD, Management of Chronic Coronary Artery Disease

Clopidogrel in CAD
• Coronary stents are getting better
• Lower risk of stent thrombosis
• Use of bare metal stents decreasing
• Low dose aspirin more accepted
45

Clopidogrel in CAD: Duration
• Duration of therapy DEPENDS on the
SETTING
• Stable ischemic heart disease
– Bare metal stent: ≥1 month
– Drug eluting stent (new gen): ≥6 month
• Acute coronary syndrome
– 12 months for all (and >12 months may be
reasonable)
46
Lifelong aspirin 81 mg daily for all!
Levine GN, et al. JACC 2016; 68(10):1082-115

• 82 year-old woman who 7 months ago:
– Progressive angina refractory to meds
– Drug eluting stent to right coronary artery
• Currently asymptomatic, EF and exam normal
• Aspirin 81 mg daily + clopidogrel 75 mg daily
• You do her pre-op consult prior to a left TKR
How do you manage timing of her surgery and the clopidogrel?
A. Stop clopidogrel now. No need to resume post-op.
B. Hold clopidogrel for surgery. Resume post-op to complete 12
months of therapy.
C. Delay surgery to complete 12 months of uninterrupted
clopidogrel.
47Michael Cullen, MD, Management of Chronic Coronary Artery Disease

What is a typical side effect of duloxetine?
A. Weight gain
B. Edema
C. Bleeding
D. Hyperhydrosis
48
James Watson, MD, Symptomatic Management of Neuropathic Pain

Meds for neuropathic pain
Duloxetine
• Often causes hyperhidrosis!
• Does NOT cause weight gain or edema.
• ?May increase bleeding when used with antiplatelets and
anticoagulants
• Start at 20 mg for neuropathic pain; goal 60 mg
Gabapentin and pregabalin
• Weight gain
• Edema
• Dizziness
• Gabapentin therapeutic dose 1800-3600 mg/day; start slow
• Pregabalin 150 mg BID; start 75 mg BID; max 300 mg BID
49

What is a typical side effect of duloxetine?
A. Weight gain
B. Edema
C. Bleeding
D. Hyperhydrosis
50
James Watson, MD, Symptomatic Management of Neuropathic Pain

• What…
– Reduces mortality of breast cancer and
recurrence risk by 50%
– Lowers risk of colon cancer by 60%
– Reduces risk of Alzheimer’s by 40%
– Reduces heart disease and HTN by 40%
– Lowers risk of stroke by 27%
– Lowers risk of type 2 DM by 58%
– Decreases depression as effectively as
fluoxetine or CBT?
51
Edward R. Laskowski, Keeping the Baby Boomer Buff: Activity as We Age

Physical Activity!
52

• Health care providers could do better
– Only 40% of US Primary Care MDs and 36%
of US medical students meet 2008 Physical
Activity Guidelines
– Only 34% of patients report receiving exercise
counseling
53

• “When I get the urge to exercise, I just lie
down until it goes away”
– R. Dangerfield
• “I have flabby thighs but fortunately my
stomach covers them.”
– A patient
54

150
75
55

Physical Activity Guidelines for Adults
• Avoid inactivity. Some physical activity is
better than none.
• For substantial health benefits, older adults
should do at least 150 minutes (2 hours 30
min) to 300 minutes (5 hours) a week of
moderate-intensity or 75 minutes (1 hour and
15 min) a week of vigorous-intensity aerobic
physical activity or an equivalent
combination.
• Any duration of activity provides health benefit
56HHS 2008, revised 2018

Physical Activity Guidelines for Adults
• Older adults should also do muscle
strengthening and balance exercise two or
more days/week
• When older adults cannot do the
recommended amount of physical activity,
they should be as physically active as their
abilities allow
57HHS 2008, revised 2018

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