Clinical decision points
Concise answers to the questions that come up between patient rooms. Each page summarizes the pivotal trials, lays out a decision algorithm, and lists the contraindications. Citations go straight to PubMed.
Cardiorenal
Can You Use SGLT2 Inhibitors at eGFR Below 30?
Empagliflozin can be initiated down to eGFR 20 mL/min/1.73 m2 per its FDA label; dapagliflozin is labeled for initiation down to eGFR 25. Both can be continued as eGFR falls further, until dialysis or transplant. Glycemic effect fades below eGFR 30, but cardiorenal benefit persists across the spectrum. Expect an acute eGFR dip of 3–5 mL/min in the first 2–4 weeks that recovers on long-term follow-up.
Read the answerWhich Anticoagulant for Atrial Fibrillation with CKD?
For AFib with CKD eGFR 30–60, apixaban has the strongest benefit-risk profile and is dose-reduced only if ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥1.5. At eGFR 15–30, apixaban remains the preferred DOAC per label and ACC consensus. Below eGFR 15 or on dialysis, individualize between apixaban and warfarin — evidence is thin and recent trials (RENAL-AF, AXADIA) were underpowered.
Read the answerDo GLP-1 Agonists Help in Heart Failure Without Diabetes?
In HFpEF with obesity (BMI ≥30), semaglutide and tirzepatide produce clinically meaningful improvements in symptoms, 6-minute walk distance, and weight in patients without diabetes. In HFrEF without diabetes, evidence is more limited and FIGHT and LIVE showed neutral-to-concerning effects on ejection fraction, so GLP-1 agonists are not routinely indicated.
Read the answerHow Long Should DAPT Continue After PCI?
For stable coronary disease post-PCI, 1–3 months of DAPT followed by P2Y12 monotherapy is non-inferior to 12 months for ischemic events and reduces bleeding. For ACS, 12 months remains the default, but MASTER DAPT and TWILIGHT support 1–3 months of DAPT followed by ticagrelor or clopidogrel monotherapy in high-bleed-risk patients.
Read the answerDo Beta-Blockers Help in Heart Failure with Preserved Ejection Fraction?
Beta-blockers have not improved outcomes in HFpEF-dedicated trials (SENIORS HFpEF subgroup, observational meta-analyses). Continue only for another indication — rate control in AFib, prior MI, or refractory hypertension. Deprescribe when chronotropic incompetence limits exercise capacity, particularly in HFpEF with baseline resting HR <70.
Read the answerCan You Use MRAs in CKD with Borderline Hyperkalemia?
Finerenone is approved for albuminuric CKD in T2D at eGFR ≥25. The FDA label specifies not initiating if baseline serum potassium is >5.0 mEq/L; FIDELIO/FIGARO used a stricter ≤4.8 enrollment cutoff. Spironolactone and eplerenone are more potent potassium raisers and are typically avoided at eGFR <30 unless hyperkalemia is managed with patiromer, sodium zirconium, or concurrent SGLT2 inhibitor. SGLT2 inhibitor co-therapy lowers hyperkalemia risk and enables MRA use in many otherwise borderline patients.
Read the answerWhen Is Perioperative Bridging Anticoagulation Necessary?
Most AFib patients on warfarin do not need bridging — BRIDGE showed no difference in thromboembolism and more bleeding with LMWH bridging. Reserve bridging for mechanical mitral valve, recent (<3 months) VTE or stroke, or very high-risk AFib (CHA2DS2-VASc ≥7 or prior stroke with rheumatic heart disease). For DOACs, bridging is not needed — simply hold per renal function.
Read the answerEndocrine
Can You Continue Metformin at eGFR 30–45?
At eGFR 30–45, metformin should be continued at a reduced dose (≤1000 mg/day) rather than stopped, per FDA 2016 relabeling. Do not initiate new therapy below eGFR 45. Discontinue entirely at eGFR <30 and hold temporarily around iodinated contrast or any acute illness that could impair renal perfusion.
Read the answerDoes Testosterone Replacement Raise Cardiovascular Risk?
TRAVERSE (2023) showed testosterone replacement is non-inferior to placebo for MACE over a mean 33-month follow-up in middle-aged/older hypogonadal men with CV risk. Mild increases in AFib, pulmonary embolism, and AKI were observed. Confirm hypogonadism with two AM total testosterone levels <300 ng/dL plus symptoms before initiating; avoid in fertility-desiring men and those with prior VTE or prostate cancer.
Read the answerDoes Continuous Glucose Monitoring Help in Non-Insulin Type 2 Diabetes?
CGM has shown an HbA1c reduction of roughly 0.3–0.4% when added to basal-insulin-treated type 2 diabetes (MOBILE). Evidence in strictly non-insulin-treated T2D is still limited but suggests a smaller benefit, similar in magnitude to adding a second oral agent. CMS expanded coverage in 2023 to include beneficiaries on any insulin and problem hypoglycemia; payer coverage for non-insulin users is expanding. Consider CGM for patients struggling with post-prandial excursions, recent diagnosis, or motivation toward lifestyle change.
Read the answerPrevention
Do Statins Prevent Events in Adults Over 75 Without Heart Disease?
Statins reduce major vascular events proportionally to LDL lowering across age groups, including over 75, per the CTT meta-analysis. Absolute benefit depends on baseline risk and life expectancy; a moderate-intensity statin is reasonable for a non-frail patient aged 75–85 with estimated 10-year ASCVD risk ≥10% and life expectancy ≥5 years. Avoid in frailty, limited prognosis, or drug-interaction-heavy polypharmacy.
Read the answerWhat Comes After Maximum Statin If LDL Remains Above Target?
Add ezetimibe first — it adds about 18–25% LDL reduction on top of a statin and is supported by IMPROVE-IT. If still above target, add a PCSK9 inhibitor (evolocumab, alirocumab) for an additional 50–60% LDL reduction with MACE benefit. Bempedoic acid and inclisiran are alternatives, particularly in statin intolerance or when injection or cost barriers exist.
Read the answerWhat Blood Pressure Target in Older Adults with Frailty?
SPRINT (ages ≥75, non-frail) supported a SBP target <120 with reduced CV events and all-cause mortality. In frail or institutionalized older adults, most guidelines settle on SBP 130–140 to balance benefit against falls, AKI, and orthostatic symptoms. Target should be individualized: measure standing BP, screen for frailty, and stop titration when symptomatic hypotension or falls occur.
Read the answerWho Still Benefits from Aspirin for Primary Prevention in 2026?
Aspirin is no longer recommended for broad primary prevention. USPSTF (2022) advises against initiation in ≥60 and supports individualized decisions in 40–59 with 10-year ASCVD ≥10% and low bleed risk. ARRIVE, ASPREE, and ASCEND each showed small ischemic benefit offset by bleeding. For most primary-prevention patients already on aspirin without a clear indication, consider discontinuing — particularly after age 70.
Read the answerPsychiatry & Pain
Which SSRI for Depression in Older Adults on Polypharmacy?
Sertraline and escitalopram are the preferred SSRIs in older adults with polypharmacy because of minimal CYP2D6/3A4 interactions and low anticholinergic burden. Avoid paroxetine (strong anticholinergic, potent 2D6 inhibitor) and fluoxetine (long half-life, strong 2D6 inhibitor). Start at half the usual adult dose and monitor sodium and QTc within 2–4 weeks.
Read the answerHow Do You Safely Taper Long-Term Opioids for Chronic Pain?
Taper long-term opioids gradually — 5–10% of the current dose every 2–4 weeks, slower once at 30–50% of starting dose. Faster tapers or forced discontinuation double overdose and suicide risk (JAMA 2021). Screen for opioid use disorder before tapering; if positive, transition to buprenorphine or methadone rather than simply tapering off.
Read the answerHow Do You Switch Between SSRIs Safely?
Most SSRI-to-SSRI switches can be done directly — stop drug A, start drug B next day at a starting dose. Cross-taper over 2 weeks for high doses or mixed mechanisms. Fluoxetine requires a 5-week washout before starting an MAOI because of its long half-life and active metabolite. Never combine SSRI + MAOI — fatal serotonin syndrome risk.
Read the answerDeprescribing
When Should You Deprescribe Long-Term Proton Pump Inhibitors?
Many patients are on long-term PPIs without a persisting indication. After 8 weeks of therapy, reassess: if reflux resolved and no Barrett esophagus, bleeding ulcer history, Zollinger-Ellison, or ongoing NSAID/antiplatelet use, step down to H2 blocker or on-demand dosing. COMPASS reassures that long-term pantoprazole is safe for most; risks of pneumonia, fracture, and C. difficile are small but real and justify periodic review.
Read the answerHow Do You Taper Long-Term Benzodiazepines in Older Adults?
Most older adults on long-term benzodiazepines can successfully taper. Switch short-acting agents (alprazolam, lorazepam) to a diazepam or clonazepam equivalent, then reduce 10–25% every 2–4 weeks, slowing the last 25% further. The EMPOWER trial showed a patient-focused educational letter doubled 6-month cessation rates. Do not abruptly stop — seizure and delirium risk is real.
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