Family Medicine & Pharmacy Podcast

Onychomycosis Jan 31, 2016

Management of Onychomycosis in Canada in 2014 http://www.ncbi.nlm.nih.gov/pubmed/25775640

Drug name:	Brand:	SA	SA Criteria	SA Approval period	Direction	SE	Monitoring
Ciclopirox 8%	Penlac (nail lacquer)	No	Not covered	N/A	Nail lacquer: Apply bid to adjacent skin and affected nails daily. Remove with alcohol every 7 days (treat 4 weeks)	dermatitis, dry skin, local burning sensation
Efinaconazole	Jublia (nail lacquer)	Not covered	Not covered	N/A	Apply to affected toenails once daily for 48 weeks	Ingorwn nail (2%), dermatitis
Terbinafine tablets	Lamisil tablets	Yes	Severe onychomycosis PLUS functional disability PLUS positive KOH or dermatophyte culture of nail from a licensed lab.	First approval: Three months Renewals: If required, up to three months.	250mg once daily for 6 weeks (fingernail); 250mg once daily for 12 weeks (toenails)	Headache (13%), diarrhea (6%), nausea, liver enzyme disorder (3%)	Monitor AST/ALT prior to initiation, repeat if used >6 weeks
Itraconazole	Sporanox	Yes	1. Immunocompromised pts/ Or 2. Pulse treatment for severe onychomycosis with functional disability PLUS confirmed lab results for candida or dermatophyte infection.	1. Immunocompromised pts approval is indefinite 2. 3 months approval for 2nd group of pts (No need for SA approval if prescribed by HIV/AIDS Dr)	Fingernail involvement: 200mg capsule twice daily for 1 week. repeat 1 week course after 3 week off time Toenails due to Trichophyton rubrum or T mentagrophytes: 200mg once daily for 12 consecutive weeks With or without fingernaikl involvement: 200mg once daily for 12 consecutive weeks Canadian labelling “Pulse dosing”: 200mg twice daily for 1 week, then repeat 1 week course twice with 3 week off time between each course	Diarrhea, nausea, headache, skin rash	Liver function in patients with pre-existing hepatic dysfunction, and in all patients being treated for longer than 1 month
fluconazole	Diflucan	Yes	1. Immunocompromised patients. OR2. Exceptions on an individual basis for fungal infections resistant to first-line medications.	1 day to indefinite (no need for HIV and AIDS Dr to apply for SA)

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Diabetes Medications and BC Coverage Information Jan 23, 2016

We are back! (Or your money back!)

In this episode, Billy and Tina discuss the PharmaCare coverage status of different classes of diabetes medications.

Sources:

BC PharmaCare Formulary: https://pcbl.hlth.gov.bc.ca/pharmacare/benefitslookup/

BC PharmaCare Special Authority: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/prescribers/special-authority

CDA Formulary Listings for Diabetes Medications in Canada by provinces and territories (Jan 2016): http://www.diabetes.ca/getmedia/c87009a8-29b6-4061-a52a-963d0b077e47/pt-formulary-listing-jan-18-2016.pdf.aspx
*In case the link doesn’t work: pt-formulary-listing-jan-18-2016

Class	drugs	Other therapeutic considerations	coverage	SA criteria
Biguanide	metformin	covered
Alpha-glucosidase inhibitor (acarbose)	acarbose	Improved postprandial control, GI side-effects	delisted
Incretin agent: DPP-4 Inhibitors	linagliptin (Trajenta)	SA	same as onglyza
sitagliptin (Januvia)	delisted
saxagliptin (Onglyza)	SA	As part of a combination treatment for type 2 diabetes mellitus, 1) When insulin NPH is not an option AND 2) After inadequate glycemic control on maximum tolerated doses of dual therapy of metformin AND a sulfonylurea.
Incretin agent: GLP-1 receptor agonists	liraglutide (Victoza)	GI side-effects	not listed
Insulin	rapid acting (Humalog, novorapid, apidra)	No dose ceiling, flexible regiments	partial coverage
short acting (Humulin R, Novolin Toronto)	covered
NPH	covered
Premixed (Humulin 30/70, Novolin 30/70, 40/60, 50/50)	covered
Premixed (Humalog mix 25, mix 50, Novomix 30)	partial coverage
glargine (Lantus)	SA	A) Type 1 DM or B) Type 2 DM > 17 years old, and 1) requiring insulin and is currently taking insulin NPH and/or pre-mix insulin daily at optimal dosing AND 2) Has experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management OR 3) Has experienced or continues to experience severe, systemic or local allergic reaction to existing insulin treatment.
detemir (Levemir)	SA	same as Lantus
new glargine (Toujeo)	not listed
Insulin secretagogue: Meglitinide	repaglinide (gluconorm)	Less hypoglycemia in context of missed meals but usually requires TID to QID dosing	not listed
Insulin secretagogue: Sulfonylurea	glyburide	Gliclazide and glimepiride associated with less hypoglycemia than glyburide	covered
gliclazide	SA (listed everywhere else in Canada)	Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses.
SGLT2 inhibitors	canagliflozin (Invokana)	UTI, genital infections, hypotension, hyperlipidemia, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia)	1 year manufacturer coverage with special plan
dapagliflozin (Forxiga)	1 year manufacturer coverage with special plan
empagliflozin (Jardiance)	not listed
TZD	rosiglitazone	CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect	delisted
pioglitazone	SA	same as onglyza
Weight loss agent (orlistat)	orlistat	GI side effects	not listed
Combination Drugs	sitagliptin and metformin (Janumet)	delisted
linagliptin and metformin (Jentadueto)	SA	same as onglyza

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What I learned from St Paul’s CME 2014 Part 1 Nov 19, 2014

This is planned to be an 8-part series highlighting the take-home points I picked up during the St. Paul’s Hospital CME Conference 2014.

Pearls from Part 1 “Internal Medicine”:

Alcoholism – Dr. Paul Farnan

Screen alcohol use disorders routinely to catch those of whom do not appear to have a significant social or occupational impairment.
Use assertive statements to convey the concern regarding someone’s alcohol use.
Peer support is strongly recommended. Patients should try multiple meetings at different groups before concluding that they are not helpful, as the groups vary in their structure and member characteristics.
Medical treatments may be considered in select patients: naltrexone, acamprosate, disulfiram.

Gout – Dr. Hyon Choi

Screen for HLA-B*5801 in Asians (esp. Chinese, Thai, and Korean patients) before starting alopurinol.
Look for concurrent metabolic disorders.
“Medication in the pocket” strategy for acute flares: colchicine 1.2mg po x1 then 0.6mg po in 1 hour.
Use losartan or CCB for concurrent hypertension.
Low-carb diet and avoid foods with highest purine content.

Cellulitis – Dr. Val Montessori

Non-purulent cellulitis, most likely caused by Group A Strep, treat with cephalexin (Keflex) 500mg po QID
Purulent cellulitis, most likely Staph Aureus but still possibly GAS, treat with Septra DS PO BID, and cover GAS with Keflex.
Complicated wounds, consult ID.

HCV – Dr. Edward Tam

New therapy more tolerable and has a 95% cure rate, but also exceedingly expensive.
Refer all HCV RNA positive patients to hepatologists for assessment of treatment.

This Changed My Practice – Dr. Steve Wong

http://thischangedmypractice.com/

OSA – Dr. Pearce Wilcox

Co-morbidities with metabolic syndrome -> screen for metabolic syndromes in patients with OSA, and vice versa

The post What I learned from St Paul’s CME 2014 Part 1 appeared first on Family Pharm Podcast.

Family Pharm Podcast – RELAUNCHED! Nov 11, 2014

After a 6-month hiatus, Tina – now a newly-hatched PHARMACIST! – and Billy teamed up to relaunch this pet project with a plan to make it more interactive and less sleep-inducing. Did it work with this unscripted episode?

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ADHD 2: medications Apr 05, 2014

Tina concentrates on the details of ADHD medications and invites your attention to the following:

Non-pharmacological therapy

behavioural therapy

Stimulants

methylphenidate
amphetamines

Non-stimulants

atomoxetine
clonidine
other antidepressants and antipsychotics (to be covered in future episodes)

The post ADHD 2: medications appeared first on Family Pharm Podcast.

ADHD 1: CADDRA Guideline Mar 31, 2014

*This episode was recorded in January 2014.

This is the topic that started it all. As Tina planned to study ADHD for school, we discussed how this would be useful information for other pharmacy students and medical trainees as well.

We looked to the comprehensive CADDRA guideline for the assessment, differential diagnoses, and treatment strategies for ADHD.

CADDRA Guideline:

http://www.caddra.ca/pdfs/caddraGuidelines2011Chapter02.pdf

ADHD Checklist on CADDRA ADHD Assessment Toolkit, page 8.20

http://www.caddra.ca/pdfs/caddraGuidelines2011_Toolkit.pdf

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**Gastroenteritis in Children** Mar 22, 2014
Billy looked at the following guidelines to summarize the approach to a child with gastroenteritis:

**UK NICE Guideline:** Diarrhoea and vomiting in children under 5 (Issued: April 2009) http://guidance.nice.org.uk/cg84

**CPS Guideline:** Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis (Posted: Nov 1, 2006) http://www.cps.ca/documents/position/oral-rehydration-therapy

History:

onset of diarrhea and/or vomiting (gastro is sudden in onset)

duration of vomiting and diarrhea (diarrhea 5-7 days, max 2 weeks; vomiting 1-2 days, max 3 days)

sick contact

pathogen exposure

travel history

History suggestive of increased risk of dehydration:

young age (esp <6mo)

low birth weight infants

>5 diarrhea in 24h

>2 vomiting in 24h

no oral intake

signs of malnutrition

Think about differential diagnosis if:

fever >38 in children younger than 3 months

fever >39 in children older than 3 months (fever workup required)

shortness of breath or tachypnoea

altered conscious state

neck stiffness

bulging fontanelle in infants

non-blanching rash

blood and/or mucus in stool

bilious (green) vomit

severe or localised abdominal pain

abdominal distension or rebound tenderness.

SSx of dehydration and shock

Table 1 in NICE

Increasing severity of dehydration

No clinically detectable dehydration

Clinical dehydration

Clinical shock

Symptoms (remote and face-to-face assessments)

Appears well

Red flag Appears to be unwell or deteriorating

–

Alert and responsive

Red flag Altered responsiveness (for example, irritable, lethargic)

Decreased level of consciousness

Normal urine output

Decreased urine output

–

Skin colour unchanged

Skin colour unchanged

Pale or mottled skin

Warm extremities

Warm extremities

Cold extremities

Signs (face-to-face assessments)

Eyes not sunken

Red flag Sunken eyes

–

Moist mucous membranes (except after a drink)

Dry mucous membranes (except for ‘mouth breather’)

–

Normal heart rate

Red flag Tachycardia

Tachycardia

Normal breathing pattern

Red flag Tachypnoea

Tachypnoea

Normal peripheral pulses

Normal peripheral pulses

Weak peripheral pulses

Normal capillary refill time

Normal capillary refill time

Prolonged capillary refill time

Normal skin turgor

Red flag Reduced skin turgor

–

Normal blood pressure

Normal blood pressure

Hypotension (decompensated shock)

Table 2 in CPS

TABLE 2

Clinical assessment of degree of dehydration *

Mild (under 5%)

Moderate (5-10%)

Severe (over 10%)

Slightly decreased urine output

Slightly increased thirst

Slightly dry mucous membrane

Slightly elevated heart rate

Decreased urine output

Moderately increased thirst

Dry mucous membrane

Elevated heart rate

Decreased skin turgor

Sunken eyes

Sunken anterior fontanelle

Markedly decreased or absent urine output

Greatly increased thirst

Very dry mucous membrane

Greatly elevated heart rate

Decreased skin turgor

Very sunken eyes

Very sunken anterior fontanelles

Lethargy

Cold extremities

Hypotension

Coma

*Some of these signs may not be present

SSx of hypernatremic dehydration:

jittery

increased muscle tone

hyperreflexia

convulsions

drowsiness or coma

Labs:

No routine blood work

Serum sodium, potassium, urea, creatinine, glucose if IV fluids or signs of hypernatremia

Blood gas if shock suspected

Stool culture if:

blood and/or mucus in stool

immunocompromized

septicemia suspected

travel history

diarrhea not improved by day 7

uncertainty about diagnosis of gastroenteritis

Blood culture if antibiotic started

Watch for HUS in E. coli O157:H7

Treatment:

Figure 1 in CPS

No dehydration

continue breastfeeding and other milk feeds

encourage fluid intake

discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration (see 1.2.1.2)

offer ORS solution as supplemental fluid to those at increased risk of dehydration (see 1.2.1.2).

Dehydration

ORT

Contraindications

IVF indicated (shock, deterioration, persistent vomiting despite NG tube)

paralytic ileus

monosaccharide malabsorption

use low-osmolarity ORS solution (240–250 mOsm/l)[5] (eg Pedialyte, Gastrolyte in Canada) for oral rehydration therapy

give 50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid

give the ORS solution frequently and in small amounts

consider supplementation with their usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs (see table 1)

plain water discouraged by CPS

consider giving the ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently

monitor the response to oral rehydration therapy by regular clinical assessment

IVF

indications:

Shock

a child with red flag symptoms or signs (see table 1) shows clinical evidence of deterioration despite oral rehydration therapy

a child persistently vomits the ORS solution, given orally or via a nasogastric tube.

Initial bolus

20mL/kg of NS, then another one if still shocked

If no response to 2 boluses, consider other causes of shock. Consult PICU.

IVF therapy

Use NS or D5NS

If shocked: add 100mL/kg for fluid deficit to maintenance

If no shocked: add 50mL/kg for fluid deficit to maintenance

Early oral rehydration recommended. Switch to ORT as early as tolerated.

IVF in Hypernatremic dehydration

Urgent consult to specialist

Use NS or D5NS still

replace slowly over 48 hours, aiming at reducing serum sodium at a rate of less than 0.5mmol/L per hour

Maintenance after rehydration

Encourage breastfeeding, milk, and fluids

Consider giving 5mL/kg of ORS after each large watery stool

If dehydration recurs, restart ORT

Antibiotic indications:

suspected or confirmed septicaemia

extra-intestinal spread of bacterial infection

younger than 6 months with salmonella gastroenteritis

patient malnourished or immunocompromised with salmonella gastroenteritis

Clostridium difficile-associated pseudomembranous enterocolitis

giardiasis

dysenteric shigellosis

dysenteric amoebiasis

cholera

Do not use antidiarrhoeal medications.

Home care

Red flags for dehydration (seek medical attention):

appearing to get more unwell

changing responsiveness (for example, irritability, lethargy)

decreased urine output

pale or mottled skin

cold extremities

Also seek medical attention if length of illness beyond the usual course:

diarrhoea: 5–7 days and in most children it stops within 2 weeks

vomiting: 1 or 2 days and in most children it stops within 3 days

If not dehydrated:

to continue usual feeds, including breast or other milk feeds

to encourage the child to drink plenty of fluids

to discourage the drinking of fruit juices and carbonated drinks

plain water also discouraged by CPS

to offer ORS solution as supplemental fluid

with clinical dehydration:

that rehydration is usually possible with ORS solution

premixed ORS preferred due to risk of error (CPS)

to give 50 ml/kg of ORS solution for rehydration plus maintenance volume over a 4-hour period

to give this amount of ORS solution in small amounts, frequently

to seek advice if the child refuses to drink the ORS solution or vomits persistently

to continue breastfeeding as well as giving the ORS solution

not to give other oral fluids unless advised

not to give solid foods.

after rehydration:

drink plenty of their usual fluids, including milk feeds if these were stopped

avoid fruit juices and carbonated drinks until the diarrhoea has stopped

reintroduce the child’s usual diet

give 5 ml/kg ORS solution after each large watery stool if you consider that the child is at increased risk of dehydration

Disease prevention

washing hands with soap (liquid if possible) in warm running water and careful drying are the most important factors in preventing the spread of gastroenteritis

hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food

towels used by infected children should not be shared

children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis

children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting

children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea.

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Pediatric UTI Mar 16, 2014

AAP Guideline on Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

http://pediatrics.aappublications.org/content/128/3/595.long

UK NICE guideline: Urinary tract infection in children

http://guidance.nice.org.uk/cg54

Summary:

For children with fever, UTI should be suspected.
For children at a very low risk for UTI, or greater than 3 years of age, a bag urine for urinalysis is an appropriate first step. If the urinalysis is suspicious for UTI, such as being positive for leukocyte esterase or nitrite, or if the children is not at a very low risk for UTI, then a catheterized urine sample should be obtained for urine culture prior to starting empiric antibiotics.
If the culture comes back negative, then antibiotics treatment covering UTI can be stopped.
Febrile UTI is presumed to be pyelonephritis, and should be investigated with Bladder and Renal Ultrasound. If the ultrasound shows structural abnormalities, or if the child has recurrent febrile UTIs, a VCUG should be considered, especially in younger children.

The post Pediatric UTI appeared first on Family Pharm Podcast.

Pediatric Fever Mar 06, 2014

The bulk of this episode is based on the UK NICE guideline: Feverish illness in children under 5, published in 2013. http://guidance.nice.org.uk/CG160

The guideline covers:

Thermometers and the detection of fever
Clinical assessment of the child with fever (using the traffic light system)
Management by remote assessment
Management by the non-paediatric practitioner
Management by the paediatric specialist (investigations summarized below)
Antipyretic interventions

The Traffic Light System in assessing risk for serious infection

This assessment tool takes into consideration color/appearance, activity, respiratory, circulation and hydration, and “other” parameters. For each parameter, their associated signs and symptoms are assigned a color code: “green” (low risk), “amber” (intermediate risk) and “red” (high risk). The table can be found here.

Age-appropriate investigations for pediatric fever

Once the risk for serious infection is determined, the following investigation should be performed:

Age	CBC diff	BC	CRP	UA/UC	LP	CXR	Stool culture
<1mo	yes	yes	yes	yes	yes	if indicated	if indicated
1-3mo	yes	yes	yes	yes	if unwell, or WBC >15 or <5M/mL	if indicated	if indicated
>=3mo, RED	yes	yes	yes	yes	yes	yes	if indicated
>=3mo, AMBER	yes	yes	yes	yes	if <1yr	if fever >39 and WBC >20	if indicated
>=3mo, GREEN	no	no	no	yes	no	no	if indicated

And at the same time, empiric parenteral antibiotic coverage for meningitis (3rd generation cephalosporin plus ampicillin/amoxicillin) should be started if LP is indicated.

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A Fib 4: Rhythm Control Medications Feb 24, 2014

Tina discusses the following rhythm control medications for atrial fibrillation:

Class 3 antiarrhythmics: blocks potassium channels and prolongs action potential duration

Amiodarone
Dronedarone
Sotalol

Class 1 antiarrhythmics: blocks sodium channels, which results in a slowed atrial conduction, lengthens atrial refractoriness, and suppresses automaticity

propafenone
flecainide

Indiana University’s P450 Drug Interaction Table: http://medicine.iupui.edu/clinpharm/ddis/clinical-table/

References:

CCS Guideline www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext
UptoDate uptodate.com
e-CPS www.e-therapeutics.ca/
RXFiles www.rxfiles.ca
Lexicomp www.lexi.com

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A Fib 3: Rate Control Medications Feb 22, 2014

Tina discusses the following rate control medications for atrial fibrillation:

Beta blockers

Bisoprolol
Metoprolol
Atenolol

Calcium channel blockers (non-dihydropyridines)

verapamil
diltiazem

Digoxin

References:

CCS Guideline www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext
UptoDate uptodate.com
e-CPS www.e-therapeutics.ca/
RXFiles www.rxfiles.ca
Lexicomp www.lexi.com

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A Fib 2: CCS 2012 Treatment Guidelines Feb 15, 2014

The CHADS2 and HAS-BLED predictive index are useful in assessing a patient’s thromboembolic risk and in predicting which antithrombotic therapy is most suitable; and that is either aspirin, clopidogrel, or anticoagulants. The 3 new anticoagulants may be simpler to use and may have less intracranial hemorrhage side effect than warfarin, there has been longer clinical experience with warfarin and an antidote is present if needed.

As for rate control and rhythm control, there is no significant difference in controlling survival and mortality between the two. Therapy is chosen based on patient’s symptoms and preference. Rate control medications include BB, non-dihydropyridine CCB, and digoxin. And rhythm control includes dronedarone, flecainide, sotalol, and amiodarone. We will go over details of these medications in the next episode.

Catheter ablation is mainly for symptom control. It may be first line for highly selected patients, is often considered 2nd line after multiple drug therapy, or for patients who failed on multiple antiarrhythmic therapy and maintenance of sinus rhythm is still desired.

Focused 2012 Update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control

http://www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext

The 2012 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Acute and Chronic Heart Failure

http://www.onlinecjc.ca/article/S0828-282X%2812%2901379-7/abstract

Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Catheter Ablation for Atrial Fibrillation/Atrial Flutter

http://www.onlinecjc.ca/article/S0828-282X(10)00012-7/fulltext

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A Fib 1: Etiology and Diagnosis Feb 09, 2014

Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Etiology and Initial Investigations

http://www.onlinecjc.ca/article/S0828-282X(10)00016-4/fulltext

CHADS2 Score

http://www.mdcalc.com/chads2-score-for-atrial-fibrillation-stroke-risk/

HAS-BLED Score

http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk/

Mayo Clinic on A Fib

http://www.mayoclinic.org/diseases-conditions/atrial-fibrillation/basics/definition/con-20027014

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CHF 2: medications Jan 11, 2014

Tina revisits ACEI, ARB, BB, and Thiazides, which were covered previously with the hypertension episodes, and introduces a few new medications as well:

Mineralocorticoid Receptor Antagonists: spironolactone and eplerenone
Loop diuretic: furosemide
Digoxin
Vasodilators: hydralazine and isosorbite dinitrate

For a quick summary of the CCS 2013 recommendations:

ACE inhibitors:

all asymptomatic patients with an EF < 35%
all symptomatic HF patients and EF < 40%

ARB:

if intolerant to ACEI
add to ACEI if intolerant or contraindicated for BB
add to ACEI and BB if NYHA class II-IV HF and EF ≤ 40% deemed at increased risk of HF events

BB:

all HF patients with an EF ≤ 40%
initiated at a low dose and titrated to the target dose or maximal tolerated dose

MRA:

patients > 55 years with mild to moderate HF during standard HF treatments with EF ≤ 30% (or ≤ 35% if QRS duration > 130 ms) and recent (6 months) hospitalization for CV disease or
with elevated BNP or NT-proBNP levels
after an MI with EF ≤ 30% and HF or
EF ≤ 30% alone in the presence of diabetes
EF < 30% and severe chronic HF (NYHA IIIB-IV) despite optimization of other recommended treatments

Diuretics:

for congestive symptoms
When acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms
persistent volume overload despite optimal medical therapy and increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low dose metolazone) may be considered as long as it is possible to closely monitor morning weight, renal function, and serum potassium

Digoxin:

patients in sinus rhythm who continue to have moderate to severe symptoms, despite optimized HF therapy
patients with chronic atrial fibrillation (AF) and poor control of ventricular rate

Isosorbide dinitrate and hydralazine:

black Canadians with HF-REF
non-black HF patients unable to tolerate an ACE inhibitor or ARB

Drug information from:

Drug monographs
CPS: http://www.e-therapeutics.ca/
Therapeutic Choices: http://www.e-therapeutics.ca/
Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx

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Diabetes 3: Insulin and Official Launch Dec 27, 2013

Classes of insulin and different treatment regimens are discussed in the third episode of a 3-part series on diabetes. This episode also marks the conclusion of our coverage of the “Big Three” of modern medicine (hypertension, dyslipidemia, and diabetes), and with it, we make an official announcement of the launch of the Family Pharm Podcast to the world (aka Facebook)!

Class	Drug	Onset	Peak	Duration
Very Rapid-acting Insulin Analogues	insulin aspart (NovoRapid)	10–15 min	60–90 min	4–5 h
insulin glulisine (Apidra)
insulin lispro (Humalog)
Rapid-acting Insulin	insulin regular (Humulin R, Novolin ge Toronto)	30–60 min	2–4 h	5–8 h
Intermediate-acting Insulin	insulin NPH (Humulin N, Novolin ge NPH)	1–2 h	5–8 h	14–18 h
Long-acting Insulin Analogues	insulin detemir (Levemir)	1.5 h	Flat, no discernible peak	24 h
insulin glargine (Lantus)
Mixed (regular/NPH) Human Insulin	insulin regular/insulin NPH Humulin 30/70, Novolin ge 30/70, 40/60, 50/50	Combination of individual components
Mixed Insulin Analogues	insulin lispro/lispro protamine Humalog Mix25, Humalog Mix50	10–15 min	Not available	Not available
Mixed Insulin Analogues	insulin aspart/aspart protamine NovoMix 30	10–15 min	60–90 min	15–18 h

Classes of insulin preparations. Adapted from Therapeutic Choices 6th edition.

CDA guideline on insulin for Type 1 diabetes, including description of basal-bolus regimen by carb counting:

http://guidelines.diabetes.ca/Browse/Chapter12

Examples of insulin regimens from CDA:

http://guidelines.diabetes.ca/Browse/Appendices/Appendix3

Self monitoring:

http://guidelines.diabetes.ca/executivesummary/ch9

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Diabetes 2: antihyperglycemics Dec 22, 2013

We reviewed the CDA 2013 guidelines on antihyperglycemic therapy for type 2 diabetes (http://guidelines.diabetes.ca/executivesummary/ch13), and explored the pharmacological properties of each of the major classes:

Biguanides: Metformin
Sulfonylureas: chlorpropamide, gliclazide, glimepiride, glyburide, and tolbutamide
Thiazolidinediones: pioglitazone and rosiglitazone
Meglitinides: Nateglinide and repaglinide
Alpha-glucosidase inhibitors: Acarbose
Dipeptidyl Peptidase-4 inhibitors (DPP4 inhibitors): Saxagliptin and sitagliptin
Glucagon Like Peptide-1 Analogues (GLP-1 analogues): Liraglutide and Exenatide

Drug information:

Drug monographs
CPS: http://www.e-therapeutics.ca/
Therapeutic Choices: http://www.e-therapeutics.ca/
Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx

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Diabetes 1: CDA 2013 Guideline Dec 16, 2013

To round up the “Big Three”, we turned out attention on diabetes. We reviewed the CDA guidelines on diabetes management and summarized the most relevant points that we think all family doctors and pharmacists would find interesting.

http://guidelines.diabetes.ca/

The CDA also prepared many apps and calculators that help HCPs make clinical decisions. As well, there are many other clinical practice guidelines on many different aspects of the care of diabetes that we cannot cover in this podcast. We recommend listeners to visit the CDA website to get a fuller picture than our synopsis here.

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Dyslipidemia 4: EBM Special Dec 15, 2013

We explore pieces of important evidence that offer a contrasting view on lipid control from the national guidelines.

We are also introducing a new EBM resource available to CMA members: InfoPOEMs, which highlights clinical studies that the editorial team finds relevant. http://www.cma.ca/clinicalresources/infopoems

Treatment group

Tools for Practice 2013: “Is Diabetes a Coronary Heart Disease Equivalent?” http://www.acfp.ca/Portals/0/docs/TFP/20131021_093004.pdf

“Though diabetes does confer an increased risk of CV events, it is not automatically equivalent to having experienced a myocardial infarction (MI) (and thus does not always warrant aggressive pharmacotherapy).

CV risk should be predicted, and therapy guided, by taking into account individual risk factors.”

InfoPOEM: “Limited data to guide lipid lowering in octogenarians” http://www.ncbi.nlm.nih.gov/pubmed/20952373

either extremes of cholesterol levels (low or high) are associated with increased mortality in patients >80 years old

Non statin lipid medications

Tools for Practice 2010: “Ezetimibe: Lowers LDL cholesterol but what else?” http://www.acfp.ca/Portals/0/docs/TFP/20111028_105411.pdf

“Eight years after being licensed by the FDA, there is still no evidence that ezetimibe reduces cardiovascular outcomes. It may be worse than niacin and there is concern about a potential increased cancer mortality risk.”

Tools for Practice 2012: “Niacin added to statins for cardiovascular disease? 1 + 1 = 1” http://www.acfp.ca/Portals/0/docs/TFP/20120502_095745.pdf

“In patients with cardiovascular disease already on statin therapy, adding niacin does not improve cardiovascular events. Among lipid treatments, only statin monotherapy has strong evidence for CVD prevention (regardless of lipid levels).”

Tools for Practice 2013: “Fibrates: Statin’s Trusty Sidekick or Lackluster Fallback?” http://www.acfp.ca/Portals/0/docs/TFP/20131007_090323.pdf

“When used alone, fibrates reduce non-fatal coronary events, but have no effect on mortality or other CV events, including stroke. Current evidence suggests fibrates provide no advantage when added to statin therapy.”

InfoPOEM: “Statins but not fibrates associated with lower risk of pancreatitis” http://www.ncbi.nlm.nih.gov/pubmed/22910758

statins significantly reduced risk of pancreatitis, where as fibrates did not

Statin dosing and efficacy

Cochrane 2014: “Statins for the primary prevention of cardiovascular disease” http://summaries.cochrane.org/CD004816/statins-for-the-primary-prevention-of-cardiovascular-disease

“All-cause mortality was reduced by statins (OR 0.86, 95% CI 0.79 to 0.94); as was combined fatal and non-fatal CVD RR 0.75 (95% CI 0.70 to 0.81), combined fatal and non-fatal CHD events RR 0.73 (95% CI 0.67 to 0.80) and combined fatal and non-fatal stroke (RR 0.78, 95% CI 0.68 to 0.89). Reduction of revascularisation rates (RR 0.62, 95% CI 0.54 to 0.72) was also seen. [...] Evidence available to date showed that primary prevention with statins is likely to be cost-effective and may improve patient quality of life. Recent findings from the Cholesterol Treatment Trialists study using individual patient data meta-analysis indicate that these benefits are similar in people at lower (< 1% per year) risk of a major cardiovascular event.”

InfoPOEM: “Statins of modest benefit for low- to moderate-risk persons (NNT ~ 80)” http://www.ncbi.nlm.nih.gov/pubmed/21989464

for a patient group with a mean 10-year risk of cardiovascular death or MI around 6.2%, the NNT for all-cause mortality was 80, for any MI was 72, and for any stroke was 97 over 10 years of statin treatment

InfoPOEM: “Statins for hyperlipidemia reduce all-cause mortality” http://www.ncbi.nlm.nih.gov/pubmed/20934984

for patients with hyperlipidemia (LDL 180 mg/dL or 4.6mmol/L), and a mean follow up of 2.7 years, number needed to treat [NNT] to reduce 1 death = 67

Tools for Practice 2012: “How does high dose statin compare to low dose in people with heart disease?” http://www.acfp.ca/Portals/0/docs/TFP/20120522_090852.pdf

“In patients with coronary heart disease, using high dose statins (compared to low-moderate dose) prevents one CHD event for every 91 patients but results in one in 47 patients discontinuing therapy due to adverse events.

However, low-moderate dose statin (compared to placebo) provides 2-3 times greater benefit than increasing to high dose statin. Therefore, getting and keeping patients on any statin is key, with dose adjusted up to tolerable levels”

Statin side effects

InfoPOEM: “Does statins cause cognitive decline?” http://www.ncbi.nlm.nih.gov/pubmed/24000778

No. Statins are not associated with cognitive decline. Actually, in patients without baseline cognitive impairment, statin use is associated with slower cognitive decline.

Tools for Practice 2013: “Statin-Induced Diabetes: Too Sweet a Deal?” http://www.acfp.ca/Portals/0/docs/TFP/20130527_014005.pdf

“Statins modestly increase blood glucose, which leads to 1 in 250 or so patients crossing the “diabetic threshold” over 5 years. Pre-existing elevated sugars, other diabetes risk factors or higher doses may slightly increase the risk. This should not change statin prescribing as they reduce cardiovascular events and all-cause mortality in appropriate patients.”

Additional tests

InfoPOEM: “CRP of little value for risk stratification” http://www.ncbi.nlm.nih.gov/pubmed/23034020

“In patients with an intermediate 10-year risk of a cardiovascular event (10% – 20%), you would have to screen more than 440 with a C-reactive protein (CRP) test to prevent 1 [cardiovascular] event. This test is quite expensive: in the neighborhood of $100 or more at many laboratories (LOE = 2a)“

(Originally published on February 1, 2014)

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Dyslipidemia 3: AHA 2013 Guideline Dec 14, 2013

We return to the topic of dyslipidemia and examined the: “2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults” http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a

Previous episodes on statins can be found here.

Major differences between AHA 2013 guideline and CCS 2012 guideline:

CCS 2012	AHA 2013
Treatment Threshold	LR (FRS<10%): consider lifestyle only IR (FRS 10-19%), if LDL <3.5mmol/L: consider lifestyle only Optional alternate target and secondary tests reasonable HR (FRS >20%), history of CVD, DM aged >40: statins LDL >5 mmol/L: statins	CVD: statins LDL > 4.9 mmol/L: statins DM aged 40-75: statins 10-year risk >7.5%: statins
Treatment Target	LDL >50% reduction LDL < 2mmol/L for IR and HR groups	No target Fixed dose statins based on initial risk assessment

Pooled Cohort Equations to estimate 10-year CVD risk: http://www.cardiosource.org/science-and-quality/practice-guidelines-and-quality-standards/2013-prevention-guideline-tools.aspx

Dr. McCormack’s discussion on patient centered EBM on KevinMD: http://www.kevinmd.com/blog/2013/12/cholesterol-guidelines-emphasize-patient-preference.html

(Originally published on January 25, 2014)

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Dyslipidemia 2: Lipid Lowering Medications Dec 13, 2013

In this episode, we listed the life-style management of dyslipidemia and lowering cardiovascular disease risk, and dived into the main classes of medications for lipid lowering: statins, niacin, fibrates, resins, and cholesterol absorption inhibitors. As an important side note, the signs and symptoms of statin-induced myopathies were discussed as well.

CCS 2012 guidelines: http://www.onlinecjc.ca/article/S0828-282X(12)01510-3

DASH diet

Mayo Clinic info sheet: http://www.mayoclinic.com/health/dash-diet/HI00047

Portfolio diet

Original research: http://jama.jamanetwork.com/article.aspx?articleid=1104262
WebMD summary: http://www.webmd.com/cholesterol-management/features/portfolio-diet-lower-cholesterol

Mediterranean Diet

Mayo Clinic info sheet: http://www.mayoclinic.com/health/mediterranean-diet/CL00011

Coming up: AHA guidelines: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.pdf+html

Drug information from:

Drug monographs
CPS: http://www.e-therapeutics.ca/
Therapeutic Choices: http://www.e-therapeutics.ca/
Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx

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Dyslipidemia 1: CCS 2012 Guideline Dec 08, 2013

We covered the key points on risk stratification and treatment targets from the 2012 CCS guideline on dyslipidemia. We also briefly highlighted cardiovascular age and secondary causes of dyslipidemia. Below are a few useful links:

2012 Update of the Canadian Cardiovascular Society (CCS) Guidelines for the Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult:

http://www.onlinecjc.ca/article/S0828-282X(12)01510-3

Framingham Risk Score worksheet, and cardiovascular age conversion chart:

http://www.ccsguidelineprograms.ca/images/stories/Dyslipidemia_Program/Tools_Resources/FRSworksheets/Lipids_EN_FRS_worksheet_v2.pdf

Dr. McCormack’s graphical FRS tool:

http://bestsciencemedicine.com/chd/calc2.html

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Hypertension 4: EBM Special Dec 02, 2013

We reviewed some evidence on the treatment of hypertension that are contradictory to the CHEP 2013 guidelines summarized in our previous episodes.

Salt restriction for hypertension

CHEP 2013: 1500 mg of sodium per day is recommended for adults age 50 years or less; 1300 mg per day if age 51 to 70 years; and 1200 mg per day if age greater than 70 years

Tools for practice: “Cutting out the sodium: The bland supremacy?” http://www.acfp.ca/Portals/0/docs/TFP/20130204_084845.pdf

“The impact of salt intake on CVD outcomes is controversial. Trials demonstrating beneficial trends enrolled patients with an average sodium intake of 3900 mg/day and reduced their intake on average by 900mg/day. More evidence with clinical outcomes is required to better define benefits/harms with different levels of daily sodium intake.”

Hypertension treatment target for diabetes

CHEP 2013: BP target for diabetes is 130/80mmHg, and 140/90 for others

Cochrane: “Blood pressure targets for hypertension in people with diabetes mellitus” http://summaries.cochrane.org/CD008277/blood-pressure-targets-in-people-with-diabetes

“The only significant benefit in the group assigned to ‘lower’ systolic blood pressure was a small reduction in the incidence of stroke (ACCORD 1.1%ARR SBP <140 vs <120), but with a significantly larger increase in the number of other serious adverse events (ARI 2%). The effect of systolic blood pressure targets on mortality was compatible with both a reduction and increase in risk. There was no benefit associated with a ‘lower’ diastolic blood pressure target (trend towards less stroke RR 0.67, 95% CI 0.42 to 1.05)”

Tools for Practice: “When Treating Blood Pressure, what is the Evidence for Specific Targets?” http://www.acfp.ca/Portals/0/docs/TFP/20111028_103346.pdf

Treating mild hypertension

CHEP 2013: treatment threshold 160/100, treatment target 140/90 for uncomplicated hypertension

Cochrane: “Pharmacotherapy for mild hypertension” http://summaries.cochrane.org/CD006742/benefits-of-antihypertensive-drugs-for-mild-hypertension-are-unclear

“For individuals with mildly elevated blood pressures(systolic blood pressure (BP) 140-159 mmHg and/or diastolic BP 90-99 mmHg) treatment for 4 to 5 years with antihypertensive drugs as compared to placebo did not reduce total mortality (RR 0.85, 95% CI 0.63, 1.15). In 7,080 participants treatment with antihypertensive drugs as compared to placebo did not reduce coronary heart disease (RR 1.12, 95% CI 0.80, 1.57), stroke (RR 0.51, 95% CI 0.24, 1.08), or total cardiovascular events (RR 0.97, 95% CI 0.72, 1.32). Withdrawals due to adverse effects were increased by drug therapy (RR 4.80, 95%CI 4.14, 5.57), Absolute risk increase (ARI) 9%.”

Which first line agent for hypertension is actually first line?

CHEP 2013: beta-blocker is considered a first line choice in patients younger than 60 years of age (Grade B), among ACEI, ARB, thiazides, CCB

Therapeutics Initiative Letter #82: “Clinical Hypertension Pearls from The Cochrane Library” http://www.ti.ubc.ca/letter82

Cochrane: “First-line drugs for hypertension” http://summaries.cochrane.org/CD001841/thiazides-best-first-choice-for-hypertension

mortality	stroke	CHD	CVS
Thiazides (19 RCTs)	RR 0.89, 95% CI 0.83, 0.96	RR 0.63, 95% CI 0.57, 0.7	RR 0.84, 95% CI 0.75, 0.95	RR 0.70, 95% CI 0.66, 0.76
Low-dose thiazides (8 RCTs)	RR 0.72, 95% CI 0.61, 0.84
high-dose thiazides (11 RCTs)	RR 1.01, 95% CI 0.85, 1.20
Beta-blockers (5 RCTs)	RR 0.96, 95% CI 0.86, 1.07	RR 0.83, 95% CI 0.72, 0.97	RR 0.90, 95% CI 0.78, 1.03	RR 0.89, 95% CI 0.81, 0.98
ACE inhibitors (3 RCTs)	RR 0.83, 95% CI 0.72-0.95	RR 0.65, 95% CI 0.52-0.82	RR 0.81, 95% CI 0.70-0.94	RR 0.76, 95% CI 0.67-0.85
Calcium-channel blocker (1 RCT)	RR 0.86 95% CI 0.68, 1.09	RR 0.58, 95% CI 0.41, 0.84	RR 0.77 95% CI 0.55, 1.09	RR 0.71, 95% CI 0.57, 0.87
ARB (no RCT)

“Most of the evidence demonstrated that first-line low-dose thiazides reduce mortality and morbidity (stroke, heart attack and heart failure). No other drug class improved health outcomes better than low-dose thiazides, and beta-blockers and high-dose thiazides were inferior. Low-dose thiazides should be the first choice drug in most patients with elevated blood pressure. Fortunately, thiazides are also very inexpensive.”

Tools for Practice: “Is hydrochlorothiazide the best thiazide diuretic for hypertension?” http://www.acfp.ca/Portals/0/docs/TFP/20120206_092015.pdf

Cochrane: “Calcium channel blockers versus other classes of drugs for hypertension” http://www.ncbi.nlm.nih.gov/pubmed/20687074

Cochrane: “Beta-blockers for hypertension” http://summaries.cochrane.org/CD002003/beta-blockers-for-hypertension

“Angiotensin receptor blockers versus ACE inhibitors: prevention of death and myocardial infarction in high-risk populations”. http://www.ncbi.nlm.nih.gov/pubmed/15701766

“Angiotensin-converting enzyme inhibitors (ACEIs), not angiotensin receptor blockers (ARBs), are preferred and effective mode of therapy in high cardiovascular risk patients.” http://www.ncbi.nlm.nih.gov/pubmed/19810392

What time should a patient take the blood pressure medications?

Tools for practice: “Taking blood pressure-lowering medications at night” http://www.acfp.ca/Portals/0/docs/TFP/20120109_102035.pdf

“Taking one or more BP meds before bed may potentially help reduce cardiovascular risk but due to limitations of the evidence, strong recommendations are difficult.”

MAPEC trial: http://www.ncbi.nlm.nih.gov/pubmed/20854139

Side note about confidence interval worship

I mentioned how a statistically insignificant risk reduction in stroke could actually be clinically significant. Check out this article by Dr McCormack et al on “How confidence intervals become confusion intervals” on this very topic. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3818447/

(Originally published on January 18, 2014.)

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Hypertension 3: antihypertensives Nov 04, 2013

Listen to Tina the pharmacist discuss the 5 first-line antihypertensives:

Thiazides
ACE Inhibitors
Angiotensin Receptor Blockers
Beta Blockers
Calcium Channel Blockers

She lists the mechanism of action, dosing, side effects, drug interactions, and cautionary notes of each drug classes and their representative drug.

This episode is wrapped up with Billy’s summary of the learning points from the 3-episode series on Hypertension:

essential hypertension is a diagnosis of exclusion. we need to consider treatable causes of hypertension especially for people who do not have the usual risk factors.
diagnosing a patient with hypertension is a careful process. for those without comorbidities or cardiovascular treatment, it can take a many as 5 visits averaging a BP of 140/90 to make a diagnosis. use home BP measurement if you suspect white coat hypertension.
the treatment threshold for uncomplicated patients is 160/100, and threshold for those with end organ damage or increased CV risk is 140/90.
a trial of lifestyle management to control BP is appropriate for most uncomplicated patients. it should always be a part of the management plan even for those who are on medication.
Treatment target is 140/90, unless the patient has diabetes, for this the threshold is 130/80.
For an elderly patient above 80 yo, systolic treatment target is 150
the first line agents are thiazides, ACEI, ARB, BB, and CCB. specific agents may be indicated for specific comorbidities
antihypertensive are among the most commonly used medications, but one must not forget that they carry many potentially serious side effects and can interact with other medications. when in doubt, consult your favorite pharmacist

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Hypertension 2: CHEP 2013 Guideline cont. Nov 04, 2013

We looked to the CHEP guidelines again for their recommendations on hypertension treatment thresholds, targets, lifestyle management, pharmacologic treatments, and suggested medications for specific comorbidities.

Treatment guidelines on CHEP:
http://www.hypertension.ca/chep

DASH diet:
http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3862329/k.4F4/Healthy_living__The_DASH_Diet_to_lower_blood_pressure.htm

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Hypertension 1: CHEP 2013 Guideline Oct 27, 2013

This is the first episode of the Family Pharm Podcast. In a series of 3 podcasts, we covered one of the most important disease entities in family practice and community pharmacies: hypertension. In episode 1, we focussed on the diagnosis of hypertension, and we also discussed briefly the secondary causes of hypertension, screening, and investigations.

I have summarized the CHEP guidelines used in this podcast on my website:
http://www.drbillylin.com/chep-summary/

CHEP guidelines on diagnosis, investigations, and management:
http://www.hypertension.ca/chep

level of CHEP recommendations explained (many of the guideline recommendations on diagnosis, lab investigations, and follow up are Level D):
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2560862/

CFPC endorses the CHEP guidelines for hypertension: http://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=1538&langType=4105

Canadian Task Force on Preventive Health Care guideline on screening:
http://canadiantaskforce.ca/guidelines/screening-for-hypertension/

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Hello! Oct 20, 2013

Hi, my name is Tina Lien, and I am a 4th year pharmacy student at the University of British Columbia. And my name is Billy Lin, a family medicine resident at UBC.

Welcome to episode 0 of what we hope to be a long and fruitful adventure, affectionately named: Family Pharm Podcast. (Pharm spelt with a PH, for pharmacy).

The Family Pharm Podcast will cover many priority topics in family medicine and community pharmacy, drawing from the “CFPC 99 topics” as well as topics from the pharmacy bible “Therapeutic Choices”. We plan to summarize the established clinical guidelines that will be used for Canadian pharmacy, med school, and family medicine licensing exams, and we hope these would be a good review for practicing clinicians and pharmacists as well.

A sample of our priority topics include hypertension, dyslipidemia, diabetes, asthma, and depression. Each podcast will present an approach to one of these diseases, including its diagnosis, common signs and symptoms, and the treatment choices including pharmacologic and nonpharmacologic options. We will include a review of the relevant drug classes associated with each disease as well.

Besides covering guidelines for exam preparation and general practice recommendations, when we feel more confident, we may also try to include evidence-based information especially if it conflicts with the guidelines. Things are always more interesting but much trickier when evidence and guidelines clash. Given that we are strong believers in EBM, we do want to stay true to our scientific conscience whenever possible. Besides, if we don’t shed light to some of the hot controversies, our colleagues and mentors in evidence-based practice might leave angry comments on iTunes Store, and we definitely don’t want that!

This podcast will of course be purely educational. None of what we say here should be taken as medical advice, and don’t assume the guidelines are always based on high quality evidence. I mean, even TC and UpToDate have this disclaimer, so please don’t take this student podcast as anything more than it is.

And what it is is a student podcast geared towards medical learners and pharmacy students, covering mostly guidelines and established clinical practices used by their exams. Occasionally, the podcast will be punctuated with EBM outbursts when we need an outlet. For a more regularly updated EBM podcast for primary care, we do recommend Mike and James’ Best Sciences Medicine Podcast.

So that’s all for today! Please stay tuned, relax, and keep your eyes on the road. Thanks for listening and we’ll talk to you next time.

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History:

SSx of dehydration and shock

Treatment:

Home care