Chiefs’ Inquiry Corner — 8/23/21

August 23, 2021


Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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 The American College of Gastroenterology’s guidelines for management of IBD recognize NSAIDs as potential triggers for IBD-related hospitalizations and disease relapses in up to one-third of patients and recommend that NSAIDs should be avoided in acute severe IBD. One meta-analysis examined evidence for these guidelines and found conflicting results. The limitations seem to have arisen from the large heterogeneity of studies included with a wide spectrum of primary endpoints. Some studies focused primarily on patients requiring hospitalization, which does exclude a large number of patients who are managed for less severe flares as outpatients. When examining the most robust studies, their findings did suggest an association between NSAID use and Crohn’s flares, but not Ulcerative Colitis. Proposed mechanisms have focused on the effects of NSAIDs on the mucosal barrier and the possible role of COX inhibition in mucosal injury.

References: Systematic Review and Meta-analysis: Association Between Acetaminophen and Non-steroidal Anti-inflammatory Drugs (NSAIDs) and Risk of Crohn’s Disease and Ulcerative Colitis Exacerbation
  Nephrogenic systemic fibrosis is a serious and potentially fatal complication that occurs in patients with AKI or severe CKD (eGFR <30 mL/min per 1.73 m2) and is traditionally associated with use of gadolinium-based contrast media. There are three groups of gadolinium-based contrast media according to American college of Radiology classification. Most cases of nephrogenic systemic fibrosis are linked to group I gadolinium-based contrast media, which are no longer used in the United States and most other countries. Newer generations of gadolinium-based contrast agents (group II and group III) have had few, if any, cases of nephrogenic systemic fibrosis, although data is lacking for group III media. A 2020 consensus statement from the American College of Radiology and the National Kidney Foundation advises the risk of nephrogenic systemic fibrosis is so low with group II gadolinium-based contrast media, the risk of withholding a clinically indicated MRI largely outweighs potential risk from administering contrast in a patient with AKI or CKD. Screening for renal dysfunction should continue when using group III gadolinium-based contrast media.

References:Use of intravenous gadolinium-based contrast media in patients with kidney disease: Consensus statements from the American College of Radiology and the National Kidney Foundation.
  The combination of history, physical exam (including orthostatic vital signs), and ECG has a diagnostic yield of over 80%, with orthostatic blood pressure being the highest yield and most cost-effective intervention. The addition of cardiac enzymes, EEG, and carotid ultrasound have a 1% yield. TTE has an additional yield of only 2%, and inpatient telemetry may be helpful in only up to 5% of cases. The current ACC/AHA guidelines take into account many of these factors, and the only Class I recommendation in the evaluation of suspected syncope is to obtain history/physical and ECG. Beyond that, the algorithm will differ based on risk factors and clinical suspicion. In patients with suspected cardiovascular abnormalities based on the initial basic evaluation, you can consider more prolonged cardiac monitoring. Check out the useful algorithms in the full guidelines.

References: 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope