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Am Fam Physician. 2022;105(2):128

How do hydrochlorothiazide and chlorthalidone compare in managing hypertension?

Chlorthalidone reduces systolic blood pressure (SBP) by 10 mm Hg more than hydrochlorothiazide at equal dosages (12.5 mg to 25 mg per day) in patients using monotherapy. Low-dose chlorthalidone (6.25 mg per day) and controlled-release hydrochlorothiazide (12.5 mg per day; not currently available in the United States) reduce 24-hour ambulatory SBP and diastolic blood pressure, whereas immediate-release hydrochlorothiazide (12.5 mg per day) may only reduce daytime SBP.

When should antibiotics be prescribed for pertussis prophylaxis?

Consider azithromycin (Zithromax) for prophylaxis within 21 days of exposure for any of the following: household contacts of patients with pertussis, those exposed to pertussis who are at high risk of severe illness, or those in close contact with someone at high risk.

What is the first-line imaging study for diagnosis of splenomegaly?

Abdominal ultrasonography is the first-line imaging study suggested to confirm a suspected diagnosis of splenomegaly.

What medications are recommended in patients with bony metastases from advanced breast cancer?

Patients with advanced breast cancer and bone metastases should be offered treatment with denosumab (Prolia) or bisphosphonates such as zoledronic acid (Reclast) or pamidronate (Aredia) to reduce the risk of fractures and hypercalcemia.

Do SGLT2 inhibitors improve mortality, cardiovascular outcomes, and renal outcomes in patients without diabetes mellitus?

According to a meta-analysis of eight studies, sodium-glucose cotransporter-2 (SGLT2) inhibitors (medications ending in -flozin, such as canagliflozin [Invokana], dapagliflozin [Farxiga], empagliflozin [Jardiance], and ertugliflozin [Steglatro]) reduce all-cause and cardiovascular mortality, reduce hospitalization for heart failure, and reduce progression of renal disease in patients with or without diabetes mellitus.

How can home blood pressure monitoring be used to diagnose hypertension?

To diagnose hypertension based on readings from a home blood pressure monitor, patients should obtain two measurements separated by at least one minute twice per day. Patients should be instructed to record their readings over the course of three (minimum) to seven (ideal) days. These readings should then be averaged.

Additional Online Only AFP Clinical Answers

What is the most effective treatment option for acute gout flares?

Low-dose colchicine, nonsteroidal anti-inflammatory drugs, and glucocorticoids delivered orally, intramuscularly, or intra-articularly are similarly effective for the treatment of acute gout flare-ups. Low-dose colchicine is similarly effective to high-dose colchicine but has fewer adverse effects.

Which pregnant patients who are interested in an out-of-hospital birth should be advised to strongly consider in-hospital delivery?

Pregnant patients without a previous vaginal delivery and patients at 41 weeks’ or more gestation should strongly consider in-hospital delivery. Patients with fetal malpresentation (breech or other), a previous cesarean delivery, or multiple gestation (twins or higher) should plan to deliver in a hospital.

In patients with diabetes mellitus who are preparing for total joint replacement, what is the preoperative A1C goal to reduce postoperative periprosthetic joint infections?

There is no definitive evidence-based A1C goal that will reduce periprosthetic joint infections for patients with diabetes who are preparing for total joint replacement. However, the risk of infection increases as the perioperative A1C level increases. Evidence suggests that a perioperative A1C level of less than 7.5 % may reduce the risk of such infections.

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