Update on Clinical Guidelines

In a packed room, Dr. O’Leary, chief of the division of hospital medicine, associate chair for quality in the department of medicine, and vice president of quality for Northwestern Memorial HealthCare in Chicago, delivered a case-based exploration of everyday clinical scenarios managed by adult hospitalists. His opening dialogue exuded a passion for evidence-based medicine, yet he humbly acknowledged his limited expertise in the extensive realm of clinical guidelines. Prior to embarking on our journey, he detailed his sources, which included the New England Journal of Medicine’s Guideline Watch, Guideline Central, and the Journal of Hospital Medicine. The points highlighted offered recent and potentially practice-altering recommendations spanning the last two years.

First up was a case of acute diverticulitis. The American College of Physicians suggests that clinicians can manage uncomplicated left-sided colonic diverticulitis on an outpatient basis, and sometimes even without antibiotics. Dr O’ Leary emphasized caution that this does not apply for those complicated events as defined by abscess, phlegmon, fistula, obstruction, bleeding, or perforation. Additionally, high-risk patients—like the one presented who was immunocompromised and met systemic inflammatory response syndrome criteria with fever and tachycardia—require special consideration and use of antibiotics for treatment.

Continuing the case study, the patient experienced an episode of atrial fibrillation during hospitalization. According to the American Heart Association, five-year recurrence rates for atrial fibrillation range from 42% to 68%. Given this elevated risk of recurrence, initiating long-term anticoagulation is recommended to reduce the risk of stroke.

Prior to discharge, the patient inquiries included medication options, diet restrictions, and potential surgery referral as this was their third episode of acute left-sided colonic diverticulitis in two years and therefore the condition was considered frequent. The good news is, we now have some knowledge on this topic to respond. The American College of Physicians recommends against mesalamine and there are no eligible studies to evaluate dietary advice. However, surgery discussion should be considered once treatment is complete to prevent relapse.

Practical wisdom from Dr. O’Leary flowed to the next case of a patient presenting with a chronic obstructive pulmonary disease (COPD) exacerbation. Hyperglycemia with more than two readings of blood glucose level greater than 180 mg/dL in 24 hours was recorded. Scheduled long-acting insulin should be added regardless of diabetes status in these circumstances to target glucose levels between 100 and 180 mg/dL. Although controversial due to a lack of specific guidelines, continuous glucose monitoring is suggested in these patients.

Dr. O’Leary continued revealing more pearls of clinical knowledge and unveiled an “Aha!” moment about hospitalized patients admitted with an exacerbation of COPD. All of them automatically meet Global Initiative for Chronic Obstructive Lung Disease, or GOLD, group E (≥ 2 moderate exacerbations or ≥ 1 exacerbation leading to hospitalization) criteria and hence should be on and have a prescription for long-acting muscarinic antagonists, or LAMA, and long-acting beta 2-agonists, or LABA. Those with eosinophils greater than 300 require the addition of inhaled corticosteroids.

Keeping on our journey, we encountered our third case—a patient diagnosed with heart failure with preserved ejection fraction (HFpEF). They are adequately diuresed and we are preparing to discharge them. To reduce their risk for adverse outcomes, hospitalists should prescribe SGLT2i, sodium-glucose cotransporter-2 inhibitors, as the first line according to the 2023 American College of Cardiology expert consensus. Interestingly, when these medications are started in the hospital there is greater long-term adherence.

Unfortunately, our patient is readmitted with atrial fibrillation. In patients with atrial fibrillation and HFrEF on guideline-directed medical therapy, catheter ablation is beneficial in improving symptoms, ventricular function, and cardiovascular outcomes (1A level of evidence). While evidence for HFpEF and symptomatic atrial fibrillation is less robust (2A), catheter ablation remains superior to drug-based rhythm control.

No comprehensive update would be complete without delving into the area of anticoagulation and bleeding—a topic that would soon take center stage at this presentation. Our final case introduced a patient already on apixaban for atrial fibrillation. This time, they presented with a lower gastrointestinal bleed—a concerning situation but a dilemma we face often. Guidelines support that patients with a life-threatening bleed on DOACs should receive reversal if the DOAC is last taken within 24 hours. After achieving source control and stopping the bleeding, resuming anticoagulation is crucial. Studies indicate that this approach reduces the risk of post-bleeding thromboembolism and mortality. The optimal timing for restarting anticoagulation remains somewhat elusive, but a window within seven days is recommended.

And just like that, Dr. O’Leary brought us to a closing summary—a moment when our minds buzzed with newfound knowledge. 

Dr. Peavler

Dr. Peavler is an adult internal medicine hospitalist and serves as the medical director of acute care quality, safety, and experience at Corewell Health West Hospitals in Grand Rapids, Mich.