Too Cautious? Rethinking Hyponatremia Correction and DVT Prophylaxis

Too Cautious? Rethinking Hyponatremia Correction and DVT Prophylaxis

With Special Guest Dr. Bianca Farley In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Bianca Farley to examine two practices driven largely by fear of rare but devastating complications: * Are we correcting severe hyponatremia too cautiously?  * Does pharmacologic DVT prophylaxis improve outcomes that actually matter to patients?  Two common hospitalist decisions. Two deeply ingrained habits. Two areas where the evidence may be more nuanced than many of us were taught.  Articles & PubMed Links Sodium Correction Rates and Outcomes Among Patients With Severe Hyponatremia Annals of Internal Medicine (2026) Retrospective cohort study of nearly 14,000 hospitalized patients with severe hyponatremia (Na ≤120 mEq/L).  Compared: * Slow correction: <8 mEq/L per 24 hours  * Moderate correction: 8–12 mEq/L per 24 hours  * Fast correction: >12 mEq/L per 24 hours  Primary Outcome * Composite of:    * 90-day mortality  * * Delayed neurologic complications  * Key Findings * Slow correction had the worst outcomes  * Moderate correction reduced adverse outcomes  * Fast correction reduced adverse outcomes even further  * Primary outcome occurred in 21% of patients overall  * Faster correction was associated with significantly lower risk of death or delayed neurologic events compared with slow correction.  What About Osmotic Demyelination Syndrome? The traditional fear of overcorrection continues to matter, particularly in high-risk populations, but this study suggests that aggressively avoiding correction may also cause harm.  Takeaway → Avoiding overcorrection remains important.  → But correcting severe hyponatremia too slowly may also worsen outcomes. → A reasonable target may be 8–10 mEq/L/day rather than reflexively aiming for the lowest possible correction rate. Pubmed: https://pubmed.ncbi.nlm.nih.gov/41587479/ Pharmacologic Thromboprophylaxis in Medical Inpatients JAMA Network Open (2026) Systematic review and network meta-analysis of 22 randomized trials involving 43,840 medical inpatients.  Compared: * Low-molecular-weight heparin (LMWH)  * Unfractionated heparin (UFH)  * Direct oral anticoagulants (DOACs)  * No pharmacologic prophylaxis  Key Findings Symptomatic VTE Baseline risk without prophylaxis: * 1.7% at 90 days  LMWH: * Reduced symptomatic VTE  * RR 0.68 (95% CI 0.49–0.94)  Clinically Relevant VTE * LMWH RR 0.57  * DOAC RR 0.58  * UFH RR 0.66  Mortality * No mortality benefit with any regimen.  Major Bleeding * DOACs increased major bleeding  * UFH increased major bleeding  * LMWH showed no statistically significant increase in major bleeding.  Interpretation Pharmacologic prophylaxis reduces VTE events, but: * Absolute VTE risk is relatively low  * Mortality is unchanged  * Bleeding risk must be considered  * Patient selection matters  Takeaway → DVT prophylaxis works, but mostly by preventing relatively uncommon events.  → Benefits are greatest in appropriately selected high-risk patients.  → LMWH appears to offer the best balance of efficacy and safety. Pubmed: https://pubmed.ncbi.nlm.nih.gov/42138924/ Practice-Changing Takeaways Severe Hyponatremia * Fear of osmotic demyelination has likely pushed many clinicians toward overly conservative correction.  * Emerging evidence suggests slow correction may itself be harmful.  * Consider targeting meaningful correction rather than simply avoiding overcorrection.  DVT Prophylaxis * Prevents VTE.  * Does not appear to reduce mortality.  * Absolute benefit is smaller than many clinicians assume.  * Risk-benefit assessment remains essential.  Clinical Pearls * The most feared complication is not always the most common complication.  * Many hospital practices persist because of rare catastrophic outcomes rather than aggregate patient outcomes.  * The best question is often not "Can this happen?" but "What happens most often?"  Bottom Line If you change nothing else this week: * Reconsider whether your severe hyponatremia patients are being corrected too slowly.  * Remember that DVT prophylaxis prevents clots, but has never clearly been shown to save lives in general medical inpatients.  Sometimes the greater danger isn't doing too much—it's doing too little. Support the show [https://subscribe.inpatientupdate.com/] Want the cited articles and key takeaways? Join the email list: https://subscribe.inpatientupdate.com/

Shorter CAP Antibiotics + The Cipro QTc Myth

With Special Guest Dr. Ernest Murray In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Ernest Murray to challenge two common antibiotic reflexes in hospital medicine: * Do hospitalized patients with community-acquired pneumonia really need 5–7 days of antibiotics? * Do we need to panic about QT prolongation every time we prescribe ciprofloxacin? Two everyday prescribing decisions. Two long-standing assumptions. Two areas where the evidence may support a more precise approach.  ARTICLES & PUBMED LINKS 3–4 Days vs ≥5 Days of Antibiotics for Community-Acquired Pneumonia Annals of Internal Medicine (2026) Target trial emulation using >55,000 CAP hospitalizations across 60+ hospitals. Compared: * 3–4 days antibiotics vs  * ≥5 days antibiotics After strict inclusion/exclusion criteria, ~5,600 clinically stable patients were analyzed. Excluded: *  Immunocompromised patients  *  Severe chronic lung disease  *  Drug-resistant organisms  *  ICU-level illness  *  COVID-19  Primary Outcomes *  30-day mortality  *  Readmissions / urgent visits  *  Antibiotic-associated C. difficile  Key Findings *  No significant difference in:  *  Mortality  *  Readmissions  *  Urgent visits  *  C. difficile infection  Interpretation In carefully selected, clinically stable CAP patients:  → 3 days may be enough pubmed: https://pubmed.ncbi.nlm.nih.gov/41974005/ Ciprofloxacin and QTc Prolongation Journal of Antimicrobial Chemotherapy (2026) Prospective study evaluating QTc before and after standard-dose ciprofloxacin. *  Baseline ECG obtained  *  Repeat ECG after reaching steady-state ciprofloxacin levels  Key Findings *  No statistically significant change in QTc  *  Mean QTc remained essentially unchanged (~415 ms)  *  Patients with significant QT prolongation had:  *  Multiple competing risk factors  *  Concurrent QT-prolonging medications  *  Electrolyte abnormalities  Interpretation For most stable patients:  → Ciprofloxacin alone does not meaningfully prolong QTc The real danger appears to be: *  Polypharmacy  *  Electrolyte derangements  *  Critical illness  *  Multiple simultaneous QT-prolonging factors  pubmed: https://pubmed.ncbi.nlm.nih.gov/41628197/ PRACTICE-CHANGING TAKEAWAYS * Community-acquired pneumonia: *  Stable patients may only need 3 days of antibiotics  *  “Minimum 5 days” is no longer absolute dogma  * Ciprofloxacin: *  QT concern should be contextual, not reflexive  *  Don’t deny patients effective oral therapy solely out of generalized QT fear  CLINICAL PEARLS *  Antibiotics may not need to “eradicate” infection completely — just shift the balance enough for the immune system to finish the job  *  Lung microbiome preservation may become increasingly important in future stewardship strategies  *  Most dangerous QT events are multifactorial, not caused by a single medication in isolation  *  Ciprofloxacin remains an extremely valuable oral option for:  *  Gram-negative bacteremia  *  Pseudomonas coverage  *  Avoiding PICC lines and prolonged IV therapy  BOTTOM LINE If you change nothing else this week: *  Consider stopping CAP antibiotics after 3 days in carefully selected stable patients  *  Use ciprofloxacin thoughtfully — but don’t reflexively fear the QTc Support the show [https://subscribe.inpatientupdate.com/] Want the cited articles and key takeaways? Join the email list: https://subscribe.inpatientupdate.com/

Fewer Bleeds, Smarter Steroids: Apixaban vs Rivaroxaban and CRP-Guided Steroids for Pneumonia

With Special Guest Dr. Adam Jaffe In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Adam Jaffe to tackle two high-impact clinical questions: * Is there a clear winner among DOACs?  * Who actually benefits from steroids in community-acquired pneumonia?  Two common decisions. New data. Practice-changing implications.  Articles & PubMed Links Apixaban vs Rivaroxaban for VTE (Head-to-Head RCT) New England Journal of Medicine (2026) Randomized trial (n=2,760) comparing: * Apixaban vs  * Rivaroxaban  Population: * Acute VTE  * Excluded: active cancer, extreme obesity, other anticoagulation indications  Key Findings * ↓ Clinically significant bleeding with apixaban  * ~54% relative risk reduction  * NNT ≈ 27  * ↓ Major bleeding (0.4% vs 2.4%)  * No difference in:  * Recurrent VTE  * Mortality  Interpretation * Same efficacy  * Less bleeding with apixaban  Takeaway → For new starts: Apixaban is the preferred DOAC pubmed: https://pubmed.ncbi.nlm.nih.gov/41812192/ Corticosteroids in Community-Acquired Pneumonia (IPD Meta-analysis) Lancet Large meta-analysis (n=3,224 across 8 RCTs) Compared: * Steroids vs  * Placebo  Primary Outcome: 30-day mortality * Absolute risk reduction: 2.2%  * NNT = 46  🔑 The Key Insight: CRP Matters When stratified by inflammation: CRP >200 * Mortality: 13% → 6%  * Absolute risk reduction ≈ 7%  * NNT ≈ 14  CRP <200 * No mortality benefit  Other Findings * ↑ Hyperglycemia (expected)  * ↑ Readmissions (7% vs 3.7%)  * No clear signal that severity scores (PSI) identify benefit  Interpretation * Steroids are not for everyone  * Benefit appears driven by high inflammatory states  Takeaway → Consider steroids in CAP only if CRP is markedly elevated (~>200) → Routine use in all pneumonia is not supported pubmed: https://pubmed.ncbi.nlm.nih.gov/39892408/ Practice-Changing Takeaways * DOACs:  * Apixaban > rivaroxaban for bleeding  * Same clot prevention → choose apixaban for new starts  * Pneumonia:  * Steroids may reduce mortality — but only in the right patient  * CRP can help identify who benefits  Clinical Pearls * The difference between DOACs is no longer “vibes” — we now have head-to-head data  * Most steroid benefit in pneumonia appears inflammatory-driven, not severity-driven  * CRP — often ignored — may actually guide meaningful decisions here  Bottom Line If you change nothing else this week: * Start apixaban for new VTE patients  * In pneumonia, check a CRP — and consider steroids if >200  Fewer bleeds. Smarter steroids. Better outcomes. Support the show [https://subscribe.inpatientupdate.com/] Want the cited articles and key takeaways? Join the email list: https://subscribe.inpatientupdate.com/

Asymptomatic Hypertension & Viral Pneumonia — Stop Overtreating

With Special Guest Dr. Austin White In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Austin White to tackle two everyday controversies that affect nearly every admission: * Asymptomatic inpatient hypertension — are PRN antihypertensives helping… or harming?  * Antibiotics for pneumonia with a positive viral panel — do these patients actually benefit?  Practical take-homes, real-world night shift scenarios, and what to change on rounds tomorrow.  ARTICLES & PUBMED LINKS: As-Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals JAMA Internal Medicine (2025) Retrospective cohort of hospitalized patients comparing: * Received PRN antihypertensives vs  * No PRN treatment Key Findings *  ↑ Acute kidney injury (HR ~1.23)  *  ↑ Rapid BP drops >25% (HR ~1.5)  *  ↑ Composite outcome (MI, stroke, death) (HR ~1.6)  * IV meds worse than oral  Interpretation *  Treating asymptomatic inpatient hypertension is associated with harm, not benefit  *  Likely mechanism: overcorrection → hypoperfusion Takeaway For asymptomatic hypertension, especially overnight: → Don’t reflexively treat the number → Focus on symptoms and underlying cause Pubmed: https://pubmed.ncbi.nlm.nih.gov/39585709/  Antibiotics for Pneumonia with Positive Viral Testing Multicenter Retrospective Study (2015–2024) Compared: * Minimal antibiotics (0–1 day) vs  * Standard CAP treatment (5–7 days) In patients with: *  Positive viral assay  *  Clinical pneumonia (hypoxia, tachypnea, imaging)  Key Findings * No difference in:  *  Mortality  *  ICU admission  *  Length of stay  *  No clear harm signal either  Interpretation *  Many patients with “pneumonia” + viral panel likely have pure viral illness *  Routine antibiotics do not improve outcomes Takeaway → If viral etiology fits the clinical picture,  don’t routinely continue antibiotics Pubmed: https://pubmed.ncbi.nlm.nih.gov/41378862/  PRACTICE-CHANGING TAKEAWAYS * Hypertension: *  Treat the patient, not the number  *  PRN antihypertensives for asymptomatic BP may cause harm  * Viral pneumonia: *  Positive viral panel + consistent story → hold antibiotics *  Reassess if clinical course worsens  * Both topics highlight: → We often overtreat out of habit, not evidence CLINICAL PEARLS FROM THE EPISODE *  The body tolerates transient high BP better than rapid drops  *  Overcorrection → ↓ cerebral perfusion → bad outcomes  *  Viral infections (even “mild” ones like rhino/adenovirus) can cause severe illness *  Antibiotic stewardship = patient safety, not just resistance  BOTTOM LINE If you change nothing else this week: *  Stop reflexively treating asymptomatic inpatient hypertension  *  Stop reflexively continuing antibiotics for viral pneumonia  Less intervention. Better outcomes. Support the show [https://subscribe.inpatientupdate.com/] Want the cited articles and key takeaways? Join the email list: https://subscribe.inpatientupdate.com/

Simple, High-Impact Changes Hospitalists Are Missing (SHM 2026 Takeaways)

With Special Guest Dr. Emily Reams In this special episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Emily Reams to break down the most practice-changing takeaways from SHM Converge 2026. No fluff — just what you can start doing on rounds tomorrow. Topics include: *  Flu shots in heart failure — real mortality benefit  *  Stopping aspirin in patients on DOACs  *  Anticoagulation in AFib despite fall risk  *  Naltrexone for alcohol use disorder — start inpatient  *  Phenobarbital for withdrawal — coming soon  *  Metformin in the hospital — dogma challenged  *  Transfusion thresholds in MI  *  “Things We Do for No Reason” highlights  Practical take-homes and what to actually change this week. Practice-Changing Highlights 💉 Flu shots in heart failure NNT ≈ 17 for death/readmission → Vaccinate before discharge during flu season 💊 Stop aspirin with DOACs ↑ bleeding and mortality without benefit → Stop aspirin ~6–12 months post-stent (most patients) 🧠 AFib + fall risk Benefit >> risk (would need >450 falls/year to offset) → Don’t withhold anticoagulation for falls alone 🍺 Alcohol use disorder * Naltrexone: start before discharge → ↓ cravings, ↓ readmissions  * Phenobarbital: increasing use, likely future standard  💊 Metformin inpatient May be safe in select patients → Consider if GFR ≥30 and no lactic acidosis 🩸 Transfusion in MI Target Hgb ~10 may reduce mortality → Evolving — keep on radar 💊 Anticoagulation updates *  Apixaban preferred over rivaroxaban  *  Reduce dose after 3–6 months for VTE  → Reassess dosing routinely Big Picture *  Biggest wins = simple changes *  Often: stop meds or use basics better *  Hospitalists have high-impact touchpoints  If You Change Nothing Else This Week *  Give flu shots in heart failure  *  Stop aspirin in DOAC patients (when appropriate)  *  Anticoagulate AFib despite fall risk  *  Start naltrexone before discharge  Small changes. Massive reach. Real impact. Support the show [https://subscribe.inpatientupdate.com/] Want the cited articles and key takeaways? Join the email list: https://subscribe.inpatientupdate.com/