SPEAKER_00 0:19

Hello and welcome to Impatient Update. I'm your host, Mason Turner, and this is your podcast for practice changing evidence for the working hospitalist. Today on the show, I'm joined by Dr. Adam Jaffe. As we lay rest to two lingering questions for hospitalists: are the doac wars finally over? Is there a right answer for oral anticoagulation? And who actually benefits from steroids when treating pneumonia? Well, Dr. Jaffe, thank you so much for being with me here today.

SPEAKER_01 0:48

My friend, it is such a pleasure.

SPEAKER_00 0:51

For the audience, Dr. Adam Jaffe is a clinical hospitalist. He works at the University of Alabama Birmingham Medical Center. He is an assistant professor of medicine and a very down-to-earth but excellent clinician and a great friend and a great buddy. And I'm just giddy to have you here with me today.

SPEAKER_01 1:14

Well, uh you're too kind. The pleasure is mine, really.

SPEAKER_00 1:19

Very gracious to be on the show, Adam and I um go back to residency and we were in the trenches together. And so really grateful to have him and excited for our discussion today. So Dr. Jaffe, tell me, how often do you start a patient on oral anticoagulation?

SPEAKER_01 1:44

It seems like it happens all the time. Like blood clots, AFib, it's just you see it all the time in the hospital, especially news starts, which I think you you asked news specifically. But yeah, this is something that we are seeing if I'm on service, you know, for a week multiple times. And whether it's, you know, they come in with the symptoms of, you know, a blood clot, or we just happen to find evidence of AFib on an EKG or find incidental PTE. It's just a part of life. There's no getting around it.

SPEAKER_00 2:18

Yeah. Um, agreed. When you start someone on a coagulation, do you do you have a go-to? Do you have a forever and always mix it up?

SPEAKER_01 2:29

No, I'm an eloquist stand. It's I think I think a lot of us are. And it's it's kind of like you said, it's just been on the vibe. You know, I feel like there's been this thought that it's the superior choice, but it had never really been tested until recently, which we'll talk about here in a minute. But that's kind of the go-to. Insurance, you know, sometimes does prohibit that. And then you look at an alternative like Zorelto. And you still feel pretty good about it. I mean, there are worse drugs like Warfrin, which is just horrible that we still have people on it.

SPEAKER_00 3:08

Unlike the the drugs, unlike the drugs we're talking about, I yeah, I do feel like it's uh a personal mission that anyone who's on Warfrine, unless they have uh fantastic reach in like APLS or something, like get them off of it. That's I'm I'm trying, but you know, the 70-something year old gentleman and his I just I like my warfriend. I have my kidman.

SPEAKER_01 3:34

That's right. They love going to clinic. It's a little social visit to get their INR checked. And I'm like, babe, join me at pickleball. It's like you you can totally hang and not have to deal with this horrible drug that just messes everything up. There are there's a better way.

SPEAKER_00 3:52

So I'm similarly always eloquent, always a pixaban, but it I saw it as like a coin flib. And I'm not, I mean, uh, it is attractive the idea that you do a one-time a day anticoagulation instead of a two-time a day med, but I'm just clinically comfortable with a pixaban. And so that's what I do. That's what I would and so it was good and interesting to see this recent trial that came out. And this was an article that was in the New England Journal of Medicine just this year, 2026, and it was bleeding risk of pixaban versus riferoxaban and acute phenothromboembolism. And so this is our first direct head-to-head randomized control trial. Let's, you know, let's slam down, let's settle it once and for all, let's figure out which one of these is better. And what they were specifically looking at was which one of these is more likely to give you a clinically significant bleeding event. So this was a, like I said, randomized trial. The in was 2,760. They looked specifically at folks with CLATS. They actually excluded anyone who needed anticoagulation for a different reason. They also excluded folks with active cancer, folks who weighed greater than 120 kgs. But they followed for three months. And like I said, the primary outcome they were looking at was clinically significant bleeding. And then they had some secondary outcomes like major bleeding and recurrent clot. And the headline takeaway is for Pixaban, the clinically significant bleeding was significantly less. There was a 54% relative risk reduction doing Apixaban instead of riveroxaband for their primary outcome. And so that gave us a number needed to treat of 27. And then major bleeding they looked at there was also um less likely in the Apixaban group um from it was 0.4% versus 2.4%. So even more impressive. Um, and then importantly, the other stuff they looked at, there was no difference. So specifically the recurrence of of clots, the recurrence of veno thrombo embolisms were essentially exactly the same between the two meds. Death ended up being the same. Um so the take-home point for me being bleeding less than a pixaban versus riveroxaban and clots the same. So I'm saying great, this reaffirms what I was already doing just based on practice pattern, but it certainly makes it so that going forward I'm gonna be even more firm on that. Um, what are what are your what are your thoughts and takeaways on this?

SPEAKER_01 6:52

Yeah, totally agree. I mean, this is something that we have been, I think, thirsting for, right?

SPEAKER_00 6:57

Mm-hmm.

SPEAKER_01 6:58

Like to finally know, like it's one thing to be going on vibes for all this time and to have these other studies where they're compared to a warfarin, and it's kind of like, well, we think that a Pixaban is the superior choice, but to put them head to head finally and have a sense and to confirm that what you've been doing is right is always we love that, but to kind of yeah, put these two, how I was gonna phrase it was these heated rivals, uh, if you will, and to uh kind of pit them against one another and see which one comes out on top. Um I know Connor and Hudson are out there listening to the podcast, so I just had to put that out there for them. We're finding out which one is the right choice for you guys. It's a Pixaban. Some a couple things with the study, I will say. Majority white, I think 90%. The uh follow up, the length of follow-up was only three months. So who knows if there's you know something out there longer. I'm sure that'll be investigated at some point. The other thing that I saw kind of just digging through the article was that there was a little bit of variability in compliance with the medicine. So the Pixaban group was, I think, 65%, whereas the riveroxaban was 75%. So that kind of makes you wonder like, was there a bleeding difference because more people were taking the drug? And if you're not taking the drug, yeah, you're probably not gonna bleed. So that was, you know, an interesting. They mentioned it, but didn't really go too into it. If you open the article, there's a Kaplan Meyer graph kind of towards the end, and it shows there's a a difference more in the beginning during the loading phase of the drug. And I honestly had forgotten about the loading phase of Zorel to because again, I never prescribe it. But uh you forget that it's a 21-day load as opposed to a week. And really after that load, the the bar graph, the the line kind of started following the same trajectory. So it really seems like that loading phase is maybe where the danger zone is for a bleed. Again, I think both are probably great drugs. It's really interesting and awesome that they're finally being compared, but and it we're still gonna do what we've been doing. But those were just a few little things.

SPEAKER_00 9:20

Yeah. Yeah. I I went to SHM Converge, and in one of the talks, I think it was the anti-coagulation talk I went to, they mentioned this trial and they threw up the meme of this kind of broy looking guy squatting over a grave, doing a little peace out sign. You know what I'm talking about? You know the one? And then on the on the headstone, they put Zurelto and the guy squatting on the grave was a pixaban. So what do you think? Do you think the the war is totally over? Do you think you'll ever prescribe river oxaban again?

SPEAKER_01 9:57

River Oxaban, it's probably I would say it's on like a couple pressers. And we're doing some goals of care conversations about river oxaban. But I'm grateful that it's there if I do need it because insurance is an issue. You know, I think I would still tell people like this is a great drug and you know, a once a day. So there are, like you said, some benefits to it. So yeah, I mean it's it's an L for River Oxaban for sure.

SPEAKER_00 10:23

Yeah, agreed. Um, and I'm with you on the caveat that it does seem like the problem and the difference is the the loading. And so I don't I don't know, maybe if they just need to the makers of River Oxaban or whatever just need to sort of reassess their loading dose and their the protocol for that. And and maybe we see some of this even out and they you know, zombie and resurrect and get out of the bed or climb out of that grave. Um, but I think my practice going forward will be similarly, I won't be telling people to stop their rifforoxaban if they're off it, because of your point that this difference is all that very first part, that's like the first three weeks or something, but I won't be starting anyone on it going forward.

SPEAKER_01 11:12

Totally agree.

SPEAKER_00 11:17

Tell me, um, is the Jaffe rule still going strong?

SPEAKER_01 11:21

Oh my god, yeah. I was worried this might come up. Um, the Jaffe rule lives on somehow. Great. And yeah, it's it's only grown for your listeners.

SPEAKER_00 11:33

Yeah, can you tell our audience what the Jaffe rule is?

SPEAKER_01 11:36

Sure. So this started, I'll say, uh, and and has evolved for sure, but you get to pick one lab value a day that you're you're just like, no, that that doesn't make sense. Clinically does not match what's going on in the room. And we're just gonna do a, you know, close our eyes, cover our ears, and pretend like we didn't see it. And you know, I'm not saying it applies to everything. Please don't jaffy rule a staph bacteremia. The lawyers would not love that. But sometimes, you know, that little bump in the white count, and you're like, we're we're just gonna ignore that. Yeah, we're we we don't care about that. So uh I put a name to this. It's something that we all do as clinicians, as a resident, and it's just stuck around. So other services will tell me, oh yeah, we jaffy ruled that. And I'm like, no, no, no, that is not for you. That is for the medicine residents only. The ER is banned from telling me that they've jaffy ruled something. So this is only gonna prop propagate this further.

SPEAKER_00 12:42

Well, knowing you and working with you and knowing you can be sarcastic, it obviously is presented as kind of a flippant like just pick one number a day and ignore it. And which when you're a co-resident or an intern, hearing you kind of speak name to that, it's very relieving because you're just like overwhelmed by every single number and they can go down a rabbit hole. So it kind of relieves that. But honestly, like it's a a kind of flippant way of saying look at the whole patient, don't get bogged down on one thing. And so, like, we joke about it and and there are times it shouldn't be used, but it really is a um the core there is something really valuable of how we think about medicine clinically.

SPEAKER_01 13:27

It is, I think it's that art of medicine piece that you can't define in a textbook. It's the gestalt thing that you only get with the reps. I mean, I was doing the math the other day. This is year five of attending hood, and I think we're still perfecting our craft, and um, that's the that's the beauty of this job. Like two plus two is not always four, and patients are just interesting, but yeah, that thing still lives.

SPEAKER_00 14:00

Well, speaking of ignoring labs, this uh we're gonna transition to a different topic here, but there is a lab that uh comes out of this that I've generally ignored, but it turns out could maybe uh give us a lot of benefit in treating patients with pneumonia. Uh, Dr. Jaffy, if you've got, let's say, a 54-year-old gentleman comes in, he's on, say the EDs put him on four liters nasal cannula, he's got respiratory symptoms, they do a chest x-ray. He's one of our few people who actually has a good low bar pneumonia. It's just pretty clear-cut. They've obviously given him probably rhocephan and azithro. They do a viral panel. We um just dropped an episode where we talked about viral panels and whether or not you treat those with antibiotics. But you do a drop viral panel and it's negative. Are you giving that guy steroids?

SPEAKER_01 15:01

No, and I'm really not thinking about it.

SPEAKER_00 15:03

Yeah, same here.

SPEAKER_01 15:05

But now you've got my whole world flipped upside down.

SPEAKER_00 15:08

Is there an ever a situation where you you have or you are treating pneumonia with steroids?

SPEAKER_01 15:16

I mean, I'm reaching back to our days in residency in the ICU when patients are critically, critically ill. And then that's really when the discussion would come up. And even then, I mean, attending to attending case to case, there was kind of reasons to, reasons not to. But outside of that, never really thinking about it.

SPEAKER_00 15:38

Yeah, no, totally. The thinking back on this, and it didn't even I don't think of it as being pneumonia, but COVID. Were y'all doing routinely doing steroids for for COVID when they came in?

SPEAKER_01 15:52

That was generally our management. If you had an O2 requirement, for sure steroids, plus minus, you know, some antiviral stuff, but that was a clear indication on our end for steroids.

SPEAKER_00 16:05

So this wasn't on my radar until recently. And again, this article was kind of binging around at um the SHM Converge conference some. And I I felt I did feel a little bit like embarrassed that it wasn't even something I had thought about. And they were talking about who is the right patient to start it. And I was like, I didn't even know it was any of them, hardly. Um, but I will say that our practice pattern pretty much matches with more or less with the guidelines. The only guideline recommendations we had were either from the Society of Critical Care Medicine said if it's severe, or the European Respiratory Society says if the patient's in shock. So kind of lining up with what we were doing, I don't think as much as for a minute, I felt like we totally missed a boat on this one. I don't know, no, we didn't really. I think it's been pretty gray. But there was a recent article out in The Lancet, corticor steroids in community acquired pneumonia, individual patient data meta-analysis. And so this was a this was kind of a complicated meta-analysis with some nuances to the methods here that you know we'll we'll focus on what we get out of this clinically and not dive into that too much, but an enormous meta-analysis from an end standpoint, uh, 3,224 patients, eight different randomized controlled trials looked at. And the big question was steroids versus placebo, is there a mortality benefit? And if so, who is it in? And so the sort of the primary outcome they were looking at was is there mortality benefit? But um, a lot of the point of the trial was doing a lot of this sort of sort of a subgroup analysis-ish thing of looking and seeing which is the patient that we're actually helping, because generally we haven't seen consistent mortality and mortality benefit in giving patients with community-acquired pneumonia antibiotics, excuse me, not antibiotics, do give them antibiotics, um, if it's bacterial, um, but steroids. And so overall, the study did find some mortality benefit at 30-day mortality and treating patients with steroids versus not, with an absolute risk reduction of 2.2%. Um and that was a number needed to treat of 46. But when they broke down the numbers a little bit more, what was really exciting, and what was that lab I was referring to that I pretty much ignore? I mean, if there's anything I'm gonna jaff your rule, a CRP is often gonna be it. But what they specifically looked at is for a C-reactive protein of greater than 204, was there a mortality benefit? And there was a significant mortality benefit with an absolute risk reduction of about 7% from 13% to 6%, and then a number needed to treat a 14%. And then when they looked at less than 204 CRP, no mortality benefit anymore, it disappeared. But when they these guidelines said severe pneumonia is what we should be treating. But when they looked at pneumonia severity index scores, if it was a four to five, no mortality benefit when compared to if you're treating less than that. So the severity didn't seem to really determine whether or not the steroids conferred a mortality benefit, but the CRP sure did. That's the big headline. A couple of just other odds and ends from the trial was in the treatment arm, there was statistically significant increase in hyperglycemia, um, which no surprise there, you're giving someone steroids, their sugar's going up. Um, and also an increase in readmissions, with which was also statistically significant, seven versus three point seven percent. Um, what are your thoughts on this? Are you convinced? Is this changing your practice? What are you thinking, Dr. Jaffey?

SPEAKER_01 20:18

Yeah, this one's this one's tricky for me, for sure. I had to chew on this one quite a bit. And I think uh I think more work needs to be done. There was an exciting article, I think it's a a couple years old now, at the Cape Cod, which looked more at the like very seriously ill high flow intubation, things like that. So they were they were kind of grading more on the severity of pneumonia and found indication for steroids. This one's more based on the CRP, which I like you, Jaffy rule a CRP frequently, probably more frequently than I'm starting folks on Eloquis in a week. Um but um yeah, it's it's I'm torn because I think it's really interesting. And the studies, you know, anytime you're putting all these different studies together, like when did they collect the CRP? There was a difference in the studies and starting the ant starting the steroids within 24 hours, some were within the first, you know, 72 or 96 hours. So uh trying to chew and digest all of this, I think maybe where I landed, and you can tell me if I'm crazy, is I think initially I would just have someone on antibiotics. And if after that, we're kind of within that 24 hours, like they got admitted overnight. I see them in the morning and they don't look better. And I feel like they should be better. If I've got a CRP, if the ER or someone thought to order it and it's over 200, and I feel like they're teetering on ICU, I might think about it. But outside of that, just to start them, I don't know. I hesitate on that.

SPEAKER_00 22:00

Yeah, this was interesting. And the fact that they looked at the CRP was interesting because it it's nice that it makes some pathophys sense and that why are we giving someone with pneumonia steroids? And that's to reduce inflammation, presumably. And so this is one time where an inflammatory marker is probably a pretty good marker of inflammation, whereas the severity of the pneumonia is really not a very good marker of whether or not there's a significant inflammatory component to this that would respond well to steroids. And so I think you and I and many of us hospitalists, inflammatory markers, we kind of roll our eyes at it, especially in someone I'm treating them for an infection. I know they're infected. Why, why would I even care? And so it's one that I rarely use and rarely order unless someone else has told me to, whether it's for a rheumatologic thing or whether it's the orthofolks trying to to determine whether or not the osteo is active or whatever. So, but I think I will. I am impressed. Um, this risk reductions, number needed to treat of 14. Like, how many pneumonias am I treating? How how long does it take me to treat 14 pneumonias? And it's, I don't know, a couple months, maybe probably less. Though this is specifically within the cohort of folks who are, it's a number needed to treat and the CRP greater than 200. I have no idea what the CRP usually is in my people with pneumonia because I don't look at it and don't pay attention to the number ever, but certainly not in someone I already know has an infection and I'm treating. But I think I I will, I'll get it. I'll, you know, get the number and kind of uh go from there. But I mean, this is a 30-day mortality benefit. Like, I like it when patients don't die in the next 30 days, most of the time. And so I'll probably be doing this a lot more. There is so much heterogeneity in this data, to your point. And there's so many different studies that my kind of looking at this, I was like, okay, I can say, what am I gonna do in my practice going forward? I can say, all right, I'll order a CRP or make sure one's gotten in someone in pneumonia and consider steroids if it's elevated greater than 200. Then my next question is what steroids am I putting them on? There's really nothing I'm all that comfortable with, other than what we did for the COVID protocol, which was dexamethasone at my institution, and putting people on 40 pret a day who are actually treating for COPD. And so I don't feel like all that comfortable with the other steroids. I did look at because you mentioned the Cape Cod trial, I looked at that just to get some thought on like what where are we seeing benefit? What are the dosing patterns? And the most, and again, those were very sick patients in this trial, but the most significant benefit was IV hydrocortisone 200 milligrams a day. And they did usually somewhere four to seven days and then tapered, which I don't know. It's hard for me to think, okay, I'm gonna be ordering these people's IV steroids unless they look sick. And so I do think that does end up pushing me a little bit more into the camp that you're saying, where if they look big sick and that CRP is over 200, then yeah, I'll do it. I'll give them steroids. Uh, if I can look at them and say, I feel confident you're not dying then in the next 30 days, then I'll say, you know, may I'm not gonna give you steroids.

SPEAKER_01 25:43

Tincture of time. It's my third favorite medicine, and I think it's fine to use it.

SPEAKER_00 25:51

My big takeaways from today, when starting anticoagulation, new start for a patient, pick a pixaban instead of river oxaban, they're less likely to bleed and will do just as well from a treating clot standpoint. But if your patient is already on riveroxaban, doesn't seem from the data there's any good reason to stop them and switch them to a pixaban. Um, and then when it comes to folks with pneumonia, consider getting inflammatory markers if you think your patient might benefit from steroids, because we have seen a statistically significant improvement in mortality with a number needed to treat of 14 if the CRP is greater than 204. That's all we've got for today. But Dr. Adam Jaffe, it's been an honor and a pleasure, and thank you so much for joining me.

SPEAKER_01 26:46

It's been so much fun. I hope I get invited back. Be well out there, missy friend.

SPEAKER_00 26:51

And to our listeners, if there's new evidence that you think hospitalists should be talking about, or if you're a clinician with insight that could help us take better care of hospitalized patients, reach out. Find Inpatient Update on social media or email me at podcast at inpatientupdate.com. And if you found this useful, share it with your colleagues, trainees, or anyone involved in inpatient care. Thanks so much for listening. This has been Inpatient Update.