A recording of this presentation is available HERE.
Hospital Medicine Updates 2026 (Jordan, 10/21/26)
A recording of this presentation is available HERE.
I gave this presentation, and I probably talked too fast and definitely stuck too much in. It's hard when there are good practice changers I want to share! If you don't want to listen to me on double speed, here are my take homes:
1) Jugular Venous Distention, Chest Xray, and elevated BNP have the best positive predictive value for volume overload in a hospitalized patient. The absence of B-lines on POCUS is a similarly good negative predictor.
https://jamanetwork.com/journals/jama/article-abstract/2845382
2) 2026 European Cardiology Society (ESC) guidelines recommend the use of a urine protein 1-2 hours after initial diuretic dose to determine if you are adequately diuresing. If urine sodium is <70mmol/L, the diuretic dose should be immediately doubled.
3) ESC has done away with HFmreF (Hooray!!!!!!!!) and now we are back to just two categories of heart failure: HFrEF (EF<50%) and HFpEF (EF>50%)
4) New 2026 A-E Risk Categories for Pulmonary Embolism help us determine first line treatment and evaluation for PE. Note that LMWH (enoxaparin) is first line treatment for Class C and D PE
5) A non-industry sponsored trial of Apixaban vs. Rivaroxaban for acute VTE (PE and DVT) publihed in March 2026 in the NEJM confirmed what we have long suspected based on observational data: Apixaban as a significantly lower bleeding risk (7.1% vs. 3.3%) and same efficacy.
6) The RENOVE trial and the API-CAT trial (both 2025) both found that reduced (half dosing) of DOAC after adequate treatment for acute VTE results in decreased bleeding and NO increased risk of recurrence. See images below for details, but you should feel totally comfortable reducing any DOAC to 1/2 dose for "maintenance/secondary prevention" after you complete treatment for acute PE/DVT.
7) The cardiologists are renaming MIs once again. I think most interesting is the concept of OMI=occlusive MI (think NSTEMI that would benefit from urgent cardiac catheterization, i.e. behaves more like a STEMI without the ST elevation) and moving away from Type 1 and Type 2 and more toward primary and secondary. Note that AI is already helping cardiologists distinguish between an NSTEMI that can be medically management and and OMI that should receive PCI.
8) 2026 AHA Guidelines recommend INTENSIFYING statins with goal LDL<55 in VERY HIGH risk patients (anyone who has already had >2 ASCVD events is very high risk) and <70 in HIGH risk. See image below for criteria clarification
10) You should resume antithrombotics (anticoagulation and/or anti-platelet agents) in patients within 1 week of an acute GI bleed. In so doing, we accept an increased risk of recurrent GI bleeds but a decrease in cardiovascular morbidity and mortality.
11) In 2026, steroids are still IN for severe (and only severe pneumonia). Should do Hydrocortisone 200mg/day, usually dose 50mg IV q6 hx 5 days, no need to taper
12) There are finally First EVER 2026 Upper extremity VTE guidelines. Know they exist. And remember and UNPROVOKED upper extremity VTE (i.e. no lines) is a totally different beast and probably needs advanced imaging and possibly urgent vascular/CT surgery.
13) Not ALL patients with cirrhosis need EGD, but you can use Liver stiffness measurements (LSM=fibrosure) and platelets to decide who REALLY needs that referral!
14) A big European study found not only NO benefit from Oseltamivir (Tamiflu) in severely ill ICU patients with influenza, but also a signal for harm. Australia has already stopped giving oseltamivir for ICU patients with Flu. Stay tuned. This flu season, we will still be giving. . . but change is a'coming.
15) 2026 NEJM RCT: In patients with hx of Afib and lower CHADSVASC (<3,4) you can safely stop DOAC 1 year after SUCCESSFUL ablation. This is not yet in guidelines.
Why Prescribe Single Pill Combinations? (Toub, 10/14/2026)
A recording of this presentation is available HERE.
Thanks so much to Dr. Danny Toub, core faculty, family doctor, and HIV specialist, who gave an awesome talk on Single Pill Combinations (SPCs). The recorded talk is available above. Dr. Toub started off by saying he wasn't going to talk about HIV meds-- and he didn't!-- instead he gave a convincing argument why we should DEFINITELY be considering SPCs for patients with hypertension, at the very least.
Single Pill Combinations (SPCs) or Single Tablet Regimens (STRs) or Fixed Dose Combinations (FDC) are, by definition, medications that contain two or more more pharmaceutical ingredients within a specified ratio, combined in one form, in the form of a tablet, capsule or injection. SPCs go way back to the 1950s (hydralazine and reserpine) and 1960s (birth control pills-- estrogen and progesterone).
There are a fair number of SPCs on the Medi-Cal formulary (see image):
including a fair number of medications to treat/prevent infectious disease (see image):
SPCs have many advantages, including 1) prevention development of drug resistance (e.g. h pylori regimens) 2) improved efficacy 3) improved adherence (only 50% of patients take medications as prescribed) in addition to 4) fewer pills, 5) less frequent dosing. Some SPCs can even deter misuse (think of Suboxone, which contains both naloxone and buprenorphine).
AND, as Dr. Toub pointed out, another advantage is SYNERGY-- that is, the unified whole is even better than the sum of all the parts.
With specific regard to hypertension, we know that only 25% of US adults with hypertension are at goal BP, less than half of patients with hypertension who are on meds are at goal, about 40% of US adults with hypertension are still only on a single medication, whereas about 75% of patients NEED a second agent to achieve BP control <140/90.
The AHA released a 2026 statement on the use of SPCs for hypertension, specifically: saying that the use of SPCs is preferred OVER stepped care (i.e. stop adding one med at a time, start out with two!)
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| https://www.ahajournals.org/doi/epub/10.1161/HYP.0000000000000258 |
The table below comes from a 2025 Lancet article summarizing how much each single agent decreases blood pressure:
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| https://pubmed.ncbi.nlm.nih.gov/40885583/ A 2009 Meta-analysis from the American Journal of Medicine, with over 11,000 patients combining 42 trials, found that adding a second agent had 5x the blood pressure effect as doubling the first agent!! It appears that the greatest bang for your buck (i.e. the most potent BP effect) comes from combing calcium channel blockers (CCBs) and angiotensin receptor blockers (ARBs). This combo reduced systolic BP by 19mmHg  AND, it gets even better: combining meds into a SPCs ironically seems to result in fewer adverse effects. For example, monotherapy with CCB is known to cause peripheral edema, but combining with an ARB seems to offset that side effect. In fact, in another Metanalysis from JAMA published in May 2026, the combination of CCB+ARB had the best profile, but even a triple combo (ARB/TZ/CCB) had better side effect profile than placebo.  While some SPCs (especially newer branded ones) wind up being more costly, some actually cost less than the combination of separate medications.  Santa Rosa Community Health (SRCH) has a Hypertension Guidelines that are taken from the Kaiser Hypertension Guidelines, generally using SPC that contains HCTZ+ lisinopril. Goal is to minimize pill burden AND get BP under control quickly with more convenience and less copays.   To be clear, SPCs are not without some disadvantages. They can be more costly. Some are gimmicks by pharma to sell "new drugs" with new names. Some combinations contain more medications than a patient actually needs (have you ever seen that cream from Mexico that combines topical steroid with anti-fungal AND anti-bacterial cream?). They can feel inflexible, lead to adverse effects and/or drug-drug interactions, and it can create a situation when a patient does have a side effect where it is very difficult to determine which agent is the culprit. *** What about for other conditions? Dr. Toub was also encouraging us to consider SPCs for Cardiovascular Kidney Metabolic Syndrome (CKM). There are multiple SCPs that target these diseases (see image) and considering the number of medications and risks of morbidity/mortality, it is reasonable to think about pill burden at the very least. While there are no studies yet confirming improved outcomes with SCPs for CKM, initial combo treatment may be considered.   In summary, SPCs are already widely accepted for many conditions, multiple guidelines recommend SCPs for Hypertension management, and they likely lead to better adherence, safer, more effective, and yet still under-used. Get to know your Medi-Cal formulary SCPs and go out and heal! |
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