Episode 404: 412. Liver Transplant - The One Referral I Doubt You Are Doing Correctly

gabapentin may increase COPD exacerbationsBenzo for ETOH might be long gone..guess what is going to replace itAnticoagulation after ablation.... what do you do with it?BBlocker in those with cirrhosis and varices

Clinicians should refer patients for liver transplant evaluation after any decompensation event—such as ascites or variceal bleeding—regardless of MELD score. After a first decompensation, 5-year mortality is 20–30%; after a second, it rises to 80–90%. Refractory ascites carries a 50% 1-year mortality, and overt hepatic encephalopathy has a 25–40% 1-year mortality. After an initial variceal bleed, the 1-year rebleeding risk is 60% without prophylaxis. There are no strict BMI or age cutoffs, and frailty has minimal effect on post-transplant outcomes. Substance use, including alcohol, is not a contraindication to referral—current guidelines no longer require a 6-month abstinence period. CitationsKing LY et al. Guidance for timely referral to liver transplantation. Clin Gastroenterol Hepatol 2025 Aug 5; [e-pub]. (https://doi.org/10.1016/j.cgh.2025.07.032)

Study Summary: Emergent Carotid Stenting in Acute Stroke ThrombectomyA multicenter registry study in Catalonia (2017–2023) evaluated outcomes in 578 patients with acute ischemic stroke and tandem lesions (large-vessel occlusion plus extracranial carotid stenosis). Patients were divided into two groups: those who received emergent carotid artery stenting (E-CAS) and those who did not (non-CAS).Key Findings: Favorable outcomes (modified Rankin Scale 0–2) were more common in the E-CAS group at: 90 days: 46% vs. 37% 1 year: Odds ratio 1.35 Recanalization rates were higher with E-CAS: 92% vs. 73% No significant differences in: Hemorrhagic transformation at 36 hours (though a trend toward higher rates with E-CAS) 1-year mortality Conclusion:Emergent carotid stenting during thrombectomy may improve functional outcomes and recanalization without significantly increasing bleeding or mortality. However, as this was not a randomized trial, results should be interpreted cautiously. Further randomized studies are needed.  Ezcurra-Díaz G et al. Emergent carotid artery stenting in patients with acute ischemic stroke with tandem lesions: One-year follow-up results from the SECURIS study. Neurology 2025 Oct 7; 105:e214067.    Gabapentinoids for Postoperative Pain: No Benefit FoundStudy Overview: A large randomized, placebo-controlled trial in the U.K. (GAP study) evaluated the effectiveness of gabapentin for postoperative pain in 1,200 patients undergoing various cardiac, thoracic, and abdominal surgeries.Intervention: Gabapentin group: 600 mg pre-op, then 300 mg twice daily for 2 days post-op Control group: Placebo Key Findings: Slight pain reduction at 1 hour post-op (4.0 vs. 3.5 on 11-point scale) No difference in pain at later time points No differences in: Opioid use Serious adverse events Length of hospital stay Commentary: Despite widespread off-label use, this large, well-designed trial found no meaningful benefit of gabapentin for postoperative pain. While short-term use appeared safe, prolonged use may pose risks (e.g., sedation, falls, respiratory depression). Clinicians are advised to reconsider routine perioperative use of gabapentinoids.  Baos S et al. Gabapentin for pain management after major surgery: A placebo-controlled, double-blinded, randomized clinical trial (the GAP study). Anesthesiology 2025 Oct; 143:851.

This massive meta-analysis of 484 randomized, double-blind, placebo-controlled trials (104,176 participants) quantified the blood pressure–lowering effects of major antihypertensive drug classes and their combinations. It introduces a new intensity-based classification system and an online calculator to predict BP-lowering efficacy based on drug, dose, and baseline BP.Study Design: 484 trials, 104,176 participants 5 major drug classes: ACE inhibitors, ARBs, β-blockers, calcium channel blockers (CCBs), and diuretics Focus: Placebo-corrected reduction in systolic BP (SBP) Mean baseline BP: 154/100 mm Hg Mean follow-up: 8.6 weeks Key Findings Monotherapy (Standard Dose): Average SBP reduction: 8.7 mm Hg By class: ACE inhibitors: 6.8 mm Hg ARBs: 8.5 mm Hg β-blockers: 8.9 mm Hg CCBs: 9.5 mm Hg Thiazide diuretics: 10.8 mm Hg Dose Doubling:Adds ~1.5 mm Hg SBP reduction (except β-blockers, which add only ~0.5 mm Hg) Dual Therapy (Standard Dose of Each): Average SBP reduction: 14.9 mm Hg Dose doubling adds ~2.5 mm Hg more Triple Therapy: SBP reduction: Up to 22.5 mm Hg (quadruple therapy even higher in one trial)

Practice Pearls: “Skip Leg Day” (Sometimes)For PAD patients who can’t tolerate leg workouts, upper body aerobic training is a strong, evidence-backed alternative. It’s not just a workaround—it’s a workout. CitationAhiskali GN, Demirel A, Yamikan H, Kutukcu EC. The Effects of Upper Extremity and Lower Extremity Aerobic Exercise Training in Patients with Peripheral Arterial Disease: A Systematic Review. J Vasc Surg. 2025. doi: 10.1016/j.jvs.2025.07.060

GLP1 drugs work but they likely need lifestyle modificationsNo convincing evidence GLP1 cause thyroid cancer in humans BUT contraindication if family history existStopping therapy usually results in weight gainInsurance coverage for weight loss is limited and variable  Semaglutide for type 2 diabetes max dose is 2.0 mg weekly Semaglutide for weight loss has a goal dose of 2.4 mg weekly Diagnose steatotic liver disease with imaging and 1 metabolic risk factor (or biopsy) After diagnosis check FIB-4: Low risk, continue to monitor with FIB-4 every 2-3yrs  Intermediate risk, order VCTE and consider referral if >F1  High risk order a VCTE and referral (20% end with SLD) 2 FDA approved medications for liver fibrosis are not cheap, expect insurance push back

OMED COPD CME

All of these articles have been talked about on questioning medicine social media on tik tok and instagram but here is an update of my recent reading

Buelt, Andrew | 2:13 PM (1 hour ago) |  | to mehttps://jamanetwork.com/journals/jama/fullarticle/2833338 Conclusions and Relevance  These results support use of metformin for treatment of symptomatic knee osteoarthritis in people with overweight or obesity. Because of the modest sample size, confirmation in a larger clinical trial is warranted.    Lee S et al. Live zoster vaccination and cardiovascular outcomes: A nationwide, South Korean study. Eur Heart J 2025 May 5; [e-pub]. (https://doi.org/10.1093/eurheartj/ehaf230) In a new South Korean study, researchers evaluated nearly 1.3 million people (age ≥50) who were entered into a nationwide database. In an analysis adjusted for numerous confounders and with an average follow-up of 6 years, people who received a VZV vaccine had significantly lower risk (by ≈25%) for overall adverse cardiovascular events, heart failure, cerebrovascular disorders, ischemic heart disease, thrombotic disorders, and arrhythmias.  https://pubmed.ncbi.nlm.nih.gov/40658956/ Conclusion: Findings indicate that VNPs were more effective than NRT for smoking cessation in this population. Given the challenges for cessation among these socially disadvantaged populations, VNPs present a promising treatment option for this priority group.   https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0326804   We did not find that haloperidol was arrhythmogenic or increased mortality in these largely short-duration trials. Further research to clarify actual clinical outcomes related to QTPmeds is important to inform safe prescribing practices.

https://www.nejm.org/doi/10.1056/NEJMoa2504544  During follow-up ranging from 12 to 52 weeks, fewer patients had severe exacerbations in the albuterol/budesonide group than in the albuterol group (5% vs. 9%). Patients in the albuterol/budesonide group had less than half the total exposure to systemic glucocorticoids as those in the albuterol group (mean, 23 vs. 62 mg per year).   Clinical Practice: This study supports the use of an as-needed combination of albuterol and budesonide in reducing severe asthma exacerbations in patients with mild asthma who are inadequately controlled by SABA alone. This aligns with current recommendations by the Global Initiative for Asthma (GINA), which advocates for an inhaled corticosteroid plus a fast-acting bronchodilator as rescue therapy across all treatment steps for patients aged 12 years and older.   https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0140673625004398?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0140673625004398%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2F  Clinical Recommendation: The findings support the practice of initiating DOAC treatment within 4 days of an acute ischemic stroke in patients with atrial fibrillation, as it reduces the risk of early recurrent ischemic stroke without increasing hemorrhagic complications. This challenges the traditional approach of delaying anticoagulation to avoid potential bleeding risks.   https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.125.074544?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org  reduce the necessity for surgical intervention. Clinical Recommendations: Given their proven cardiovascular benefits, safety profile, and cost-effectiveness, high-dose statins should be strongly considered for patients with small AAAs, particularly those without contraindications. Future Directions: