Update in Clinical Guidelines-Slides

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This clinical guideline update by Kevin O’Leary MD highlights recent recommendations relevant to adult hospital medicine through case-based scenarios.<br /><br />For acute uncomplicated left-sided colonic diverticulitis, the American College of Physicians (ACP) suggests outpatient management and selective avoidance of antibiotics in patients without systemic inflammation or immunosuppression. Complicated cases still require antibiotics and inpatient care.<br /><br />Regarding acute atrial fibrillation (AF) during hospitalization, recurrence rates are high (42–68%) in the setting of acute illness. Long-term anticoagulation based on stroke risk (e.g., CHA2DS2-VASc score) is reasonable following initial AF, with cardiac event monitoring as indicated. Catheter ablation is increasingly favored over medical rhythm control for symptomatic AF in heart failure patients to improve outcomes.<br /><br />For recurrent diverticulitis (≥3 episodes in 2 years), ACP recommends discussing surgery; mesalamine and dietary restrictions like avoiding nuts and seeds are not supported by evidence.<br /><br />In COPD exacerbations, GOLD guidelines categorize patients into groups; Group E (≥2 moderate exacerbations or ≥1 hospitalization) should receive combination long-acting bronchodilators (LABA+LAMA). Addition of inhaled corticosteroids (ICS) depends on eosinophil counts (≥300 cells/µL).<br /><br />Management of inpatient hyperglycemia includes correctional insulin initially, escalating to scheduled insulin if glucose exceeds 180 mg/dL twice in 24 hours, especially for steroid-induced hyperglycemia. Continuous glucose monitoring (CGM) is suggested over point-of-care testing in insulin-treated hospitalized patients.<br /><br />For heart failure with preserved ejection fraction (HFpEF), SGLT2 inhibitors reduce hospitalizations and cardiovascular mortality and should be started during hospitalization when possible. Guideline-directed medical therapy initiated inpatient improves adherence.<br /><br />In cases of life-threatening lower GI bleeding on direct oral anticoagulants (DOACs) like apixaban, reversal with andexanet alfa is advised if DOAC was taken within 24 hours. Anticoagulation should be resumed within 7 days to reduce thromboembolic risk.<br /><br />Key practice points:<br />- Use antibiotics judiciously in diverticulitis.<br />- Consider anticoagulation for new-onset AF in acute illness.<br />- Refer recurrent diverticulitis for surgery.<br />- Treat steroid-induced hyperglycemia with insulin regimens.<br />- Employ LABA+LAMA for high-risk COPD patients.<br />- Initiate SGLT2 inhibitors early in HFpEF.<br />- Consider catheter ablation for AF in heart failure.<br />- Reverse DOAC in severe GI bleeding and resume anticoagulation promptly.<br /><br />These guideline updates synthesize recent evidence to inform inpatient management and improve patient outcomes in common hospital medicine conditions.
Keywords
acute uncomplicated diverticulitis
antibiotic stewardship
acute atrial fibrillation
CHA2DS2-VASc score
catheter ablation
recurrent diverticulitis surgery
COPD exacerbation management
steroid-induced hyperglycemia
SGLT2 inhibitors in HFpEF
DOAC reversal with andexanet alfa