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, clinical pharmacist Lindsay Deloney joins me for one big question and three pharmacy quick hits. First, phenobarbital for alcohol withdrawal. When these patients land on the medical floor after getting phenobarb in the ED, what are we supposed to do with it? And what does the evidence actually tell us about using a structured phenobarbital pathway outside of the ICU? Then a little bit of that patented pharmacist gentle guidance. Does starting steroids mean we should automatically add a PPI? When should a ceftriaxone susceptible result actually make you nervous because of AMP C? And if a patient is still on full dose of PIXPAN years after a VTE, should we be rethinking that plan? Let's get into it. Well, Lindsay, thank you so much for being here.

SPEAKER_01 1:20

Yeah, happy to be here.

SPEAKER_00 1:22

So let's start off with, as I said at the top, doing any IV phenobarb. So we're running into this more and more now. A patient admitted from the ED, alcohol withdrawal, gets phenobarb down there, they come to the floor, and then as the hospitalists, we're asking, should we keep doing this? Should we do something different? Is this safe? How do we dose it? How often are you getting these types of calls from hospitalists?

SPEAKER_01 1:45

I mean, weekly for sure. You know, I would say at least, you know, there's one or two on my teams at all times, I would say. I mean, so it's super common. And questions about phenobarb are also super common from both teaching teams and hospitalists. I feel like that's probably one of the most frequent questions or most consistent questions we get because at our institution we do not have a protocol right now for for for floor patients. So we are like so frequently getting the call, hey, my patient got one or two doses of phenobarb in the ED. I want to continue or should I continue? And what do I do?

SPEAKER_00 2:12

Yeah.

SPEAKER_01 2:12

And how do I do it?

SPEAKER_00 2:14

Um yeah. I feel like the phenobarb, and I think I've said this even in an episode before, was this drug that in medical school, it was almost just like this is the dirtier version of benzos. And like it's more a historic thing. It's not really used anymore. And then all of a sudden, I feel like me and a lot of other hospital medicine clinicians are just like all of a sudden, like, where is this coming from? All of a sudden, everyone's ordering it at the ED, what are they doing? And then like, I see you, what are they doing? And then it's everything's closing in on us. And it's like, okay, we're doing this now. Yeah. So I think a lot of us have the question of like, why are we doing this? What's the benefit? Should we be doing this? How do we do this?

SPEAKER_01 2:56

I mean, I think that, like I said, I'm not convinced that phenobarb is better than benzos, but I think there are in theory reasons why phenobarbital may be more preferred or may have benefits that benzos don't have. So I think number one, I my favorite thing about it, or it has a dual mechanism of action. So not only does it act on the GABA receptors, but it also acts on the glutamate receptors and kind of has that it works both ways. And that's, you know, a lot of times when we see benzorefractory patients, it's because their, you know, GABA receptors are so altered that the benzos just don't work. And that's why we see such a big range in patients, but they require. Some patient could require like 2.5 TID of volume, and some need 20 QID. It's a lot bigger of a range. And I feel like phenobarb is much more predictable from my experience because it has that dual mechanism of action that we can rely on. And then, you know, other benefits, it has the really long half-life. So, like in theory, once you load them up, it should be a nice self-taper that is a little bit smoother than you know, benzos where you have the peaks and the troughs. So once you get them to a good place, in theory, you should be able to kind of let them ride it out and not have to do much.

SPEAKER_00 3:58

But it's pretty compelling the long half-life that's it's like days, right?

SPEAKER_01 4:04

72-ish hours, yeah. So I mean, once you get them loaded, like it they tend to do pretty well.

SPEAKER_02 4:09

Yeah, right.

SPEAKER_01 4:10

Yeah. Yeah. And there is, you know, a common question we get is do we do an oral taper or an IV taper scheduled after the full 10 to 15 megapercake load? And I used to say no, it's up tapers. And then in my work, like creating our institution institutional protocol, I feel like I look into the data a little bit more. And now I'm on the taper train, a short taper train. So like doing like 65 Q12 for two two doses and then 32.5, you know, for a short taper, but in theory, that you load them up, it'll keep them there for like the first 72-ish hours, and then you start loading so that way you don't potentially load them really early into their withdrawal, and then they start having breakthrough as the Athena barb st starts a self-tapper.

SPEAKER_02 4:49

Okay.

SPEAKER_00 4:50

And are you so with this, this would all this taper would all be in theory, probably while they're still in the hospital and then not needing to send them out on anything oral.

SPEAKER_01 5:00

Correct. You know, like yeah, we're usually watching these patients even if we fully load them, you know, 48 hours. So you load them on day one, give them a dose, two doses on day two, and then maybe a dose in the morning on day three if they're leaving, or two doses if they stay. Um so I don't think it's something that I would like advocate for sending them out with. But while they're here, I think it makes sense.

SPEAKER_00 5:18

Aaron Powell So the article specifically that we talked about some and we've sort of used to guide our protocol here has been this JAMA article from 2025 entitled Hospital-wide Implementation, Clinical Outcomes and Safety of Phenobarbitol for Alcohol Withdrawal. This was a retrospective pre-post quality improvement study. It looked at 154 patients from before and then 100 from after they implement the protocol. And it's looking at exactly this giving a specific IV phenobarb protocol, including patients on the floor, and asking, is it effective and is it safe? So at the front end, they gave 15 MIGs per kig of IV load of phenobarb, or sometimes 10 MIGs per kig if they thought the patient was lower risk or they were worried about doing the higher dose. This looked at patients with a significant portion of them were on the floor. 75.6% didn't have any ICU care. So this is really our patient population, the four patients. And they looked at these outcomes. CWA scores, no significant difference in the first 24 hours, and then the maximum daily CWA thereafter was lowered by 4.3 points at 24 to 48 hours. And this was a statistically significant reduction. 4.2 points at 48 to 72 hours, and 5 point average CWA score reduction at 72 to 96 hours. All of those statistically significant. They also significantly lowered the treatment duration. The treatment duration was 30 hours lower in the phenobarbital group compared to standard paratherapy group. Time to discharge 2.2 days better in the IV phenobar protocol group than it was in the other group. And the big question we have is safety. And they saw no significant difference in any of the metrics they looked at for safety, like mortality, 3.9% versus 4%. They looked at intubations, not statistically significant difference, but a relatively low end. So again, a caveat of this is relatively small sample size, and it's not a randomized controlled trial, but a good pre and post-trial.

SPEAKER_01 7:48

But, and we can talk about this later, they they loaded up 15 mix per cake, which is definitely on the highest end of the literature or higher end of the literature. Vast majority of studies do 10, maybe 12. Um, so that is one difference that we're doing with our protocol is we're only doing 10 because most patients do okay with that.

SPEAKER_00 8:03

So I'm I'm pretty impressed. I'm almost like, I see this and I'm like, what are we talking about? I'm convinced phenobarf is better because if we can give it to people and they can get, to your point, better control of their symptoms, and it's evidenced by the CWA scores being better, and then we can get them out of the hospital sooner. And now I'm suspicious, obviously, like we're talking about that the being on treatment less is the drugs being in their system just as much. It's just the convenience of the sort of natural taper, but that does or the long half-life at the end of things. But it does, if it gets them out of the hospital sooner, like this is great.

SPEAKER_01 8:37

Yeah. I mean, uh again, you know, I'm not convinced by a retrospective before and after cohort that like it's better. And like, but I mean, a lot of the studies have shown shorter duration of action or shorter duration and shorter hospital length of stay and shorter ICU length of stay. So I mean, I do think that there's something there. This study doesn't really talk about what benzos they were getting, were they getting bright benzos, you know. So there's so many like confounders, but you know, it does make you think like, should we be doing this? And then, you know, the biggest issue we had, we've been trying to work on a protocol for years. And this is the first study that actually included four patients getting Ivy phenobarbital. So this really helped us justify protocolizing it and like using it on the floor. But I think another like strength of this study is there are several different ways to dose phenobarbital. And I think that's where a lot of the confusion comes in because people see like this study did it this way, or like, how do I do this? You know, and our current practice in the ED is dosing by vial size. So they get 260 times one, and then they get 130s up to 10 mix per keg. And then in the ICU, our protocol is give 10 mix per keg, like they did in this study, as a single dose infusion, like over 30 minutes. And then there's like a lot of floor studies that do I am dosing, and they break it up into four mix per keg, then three, then three. So that there's just so much confusion about like, how should I be dosing this? Um, and this study showed us that the easiest way to dose is just a single dose, one done, over 30 minutes, and that is safe. And like I said, they used a higher than normal dose, so it really makes us feel comfortable about with that. Yeah. And I think, you know, take home from the hospital that's who's nervous is like, just get them 10 mix per keg, whatever way you can. If you want to keep doing 130s, it's based on ideal body weight. So that's another big, like, it's a big difference if you go remember that. But just try to get them a 10 mix per keg and then you can have PRN because it has a pretty fast onset of actions. Like once you load them up, if they're not, if they're still not doing well, then you can give them a dose pretty quickly, and then you can see the effect pretty quickly. So we did one mix per kig every hour up to five doses. Um so you can keep loading them quickly if they're still having symptoms, and then hopefully get them to a good place, and you can go up to 15 mix per kig within the first 24 hours. I think that again, like most the the the what I hear is I'm concerned about safety. You know, what I usually tell people is that it's when we give phenobarb for status, we're giving 20 mix per kig. So these are substantially lower doses, um, and that's where a lot of the scary adverse effects have been noted in that literature.

SPEAKER_00 10:54

So we're essentially giving half that I put to you your question of like what are the the habits or the things that you often see done that maybe should be done differently or could be done differently, or maybe something we're missing. And I had to pull it out of you a little bit because I don't want to call out all the hospitals. To be all that intense. But I am was it so interested in your perspective. So, what do you think is your biggest thing that is a medical habit, a medication habit that hospitalists have that we should be reconsidering?

SPEAKER_01 11:31

One thing that just is very not evidence-based is the routine use of using PPIs for gastroprotection for patients receiving steroids. And, you know, I was a critical care resident. So we didn't even give PPIs for steroids without other indications in the unit. So when I started working with medicine, I'm like, why is everyone getting a PPI? And I at the beginning I did push back on them because like there's not evidence out there. There's not any, there's no single study that has shown that PPIs decrease the risk of peptic ulcers in patients receiving steroids. Like I said, I I thought it at first, but then it's like, I don't want to be the PPI police. I don't want to, you know, annoy the crap out of everyone being like, take off the PPI. And then it makes it even harder when it's consultant driven. So I just kind of gave up. Yeah, or you know, like I I stopped bringing it up just because it's such an ingrained practice.

SPEAKER_00 12:19

Yeah, the and to that point, the there was the Things We Do for No Reason article in the Journal of Hospital Medicine from 2023. And the big thing is old meta-analysis from 1994 looking at randomized control trials comparing getting steroids to not getting steroids, compared GI ulcers, it found no difference. Big study looked at 93 different randomized control trials. Then there was another study from BMJ 2014 called Corticosteroids and Risk of Gastrointestinal Bleeding, a systematic review and meta-analysis. It looked at 159 studies and of 33,000. It found an odd ratio of 1.4 for GI bleeding or perforation, comparing steroids to no steroids. But importantly, that was confounded by a significant ICU population in patients with other risk factors. Within ambulatory patients, there was no statistically significant difference in the likelihood of GI complications, GI bleeding or perforation specifically between steroids versus not steroids. But again, when we looked at a more inclusive patients, there maybe was some risk. But the question is, is the PPI even doing anything? And so there was Wohig et al. produced a 2026 study. There were two emulated targeted trials. In the gastroprotective meds group, PPI, antihistamine 1.03%, no prophylaxis, 0.78%. And this wasn't statistically significant. So looking at this, do these PPIs or maybe Femodidine, does it reduce the risk of getting ulcers in patients that are on steroids, getting any sort of serious GI effects events, looking out even at 12 months, it found no difference. And this is another one of those classic things where I feel like so often in medicine, if we are doing to something to someone that has a potential complication, we are so afraid of that happening that sometimes we overdo and do things for no reason.

SPEAKER_02 14:52

Yeah.

SPEAKER_00 14:52

And give a medicine to find another medicine. And so, I mean, we've certainly seen particularly more insets, high inset use.

SPEAKER_01 15:00

Yes, and that's 100%.

SPEAKER_00 15:02

You get these terrible, terrible GI bleeds. You're in the history of someone with a GI bleed and they've taken a whole bunch of ibuprofen and you're like, okay, bada bing, bada boom, we're done.

SPEAKER_02 15:09

Yeah.

SPEAKER_00 15:10

But the steroids, not so much, not so clear in the data. And to your point, as they they compiled in this article, and I encourage people to read the whole things we do for no reason article that they cite a lot of this stuff, it's no clear evidence that it is causing a benefit in any way or reducing the risk of these ulcers. Certainly, people in the ICU will get ulcers some, but it's probably more just the stress of the ICU itself than it is the specifically the steroids.

SPEAKER_01 15:40

Yeah, and I'm pretty sure when I was a resident and part of our steroid uh stress ulcer prophylaxis guidelines, steroids were a minor criteria. So you had to have several minor criteria to get stress ulcer prophylaxis. To my knowledge, I'm pretty sure they have removed steroids from the SECM guidelines as a risk factor because the evidence is so poor. So it's not even a consideration anymore for them. So for us to be doing on the floor, you know, is that what we should be doing?

SPEAKER_00 16:02

Yeah. And these aren't, these are just like any medication, there are potential side effects. And whether you're ordering the PPI or you're doing Febodidine or whatever, this is something that potentially has a side effect, and that I bet that not uncommonly people just kind of get stuck on them.

SPEAKER_02 16:19

Yeah.

SPEAKER_00 16:20

But it was interesting to look at the data a little bit more. And I'm pretty much converted and I'm I'm happy to fight on things. And so I think I probably will. Uh being the one who puts in the orders, probably will be ignoring the line in a lot of consultants' notes mostly.

SPEAKER_01 16:34

Yeah.

SPEAKER_00 16:34

Uh just because I don't I don't want to do things for no reason.

SPEAKER_01 16:37

You know, and like so they're not benigned. I feel like, you know, again, like you said, no one wants to have an adverse effect. And that's to be honest, like what stopped me, you know, I don't want to make this huge case to stop it. And then it's genetic bleed, you know. But I think they get stuck on, and we they have so many adverse effects, you know, that c thoughtful consideration of like, okay, do they have any other risk factors? Are they on anec regulation, NSAIDs, platelets, previous dry bleeds, like that'll that I can get behind. But for just the regular person who's on steroids, I don't know. I don't I don't think I would do it.

SPEAKER_00 17:09

All right. I like it. Okay. Give us number two.

SPEAKER_01 17:13

I think I would rank of number two being not reassessing a PIX band dosing for patients who are on extended treatment for their previous VTEs. So I think that, you know, and again, I'm guilty of this too. Patient on a Pixaban 5 BID for a remote DVT. And we just kind of that's their home dose. We continue it, we don't reassess it. And as we'll probably talk about, you know, the evidence for doing this, doing extended low dose, so like 2.5 milligrams BID is not new, but within the last year, there have been three studies that have been published looking at it. So I think it's a very hot topic. And I think that moving forward, it's it's a a good opportunity for hospitalists or for the middle teams to kind of intervene and say, hey, do they need this high dose?

SPEAKER_00 17:56

I distinctly remember seeing a patient at some point and saying, why is this patient on 2.5 BID of a pixaban? Like that's and I'm just hung up on the AFib criteria of like, okay, you know, that's that's all about their weight and their um their renal function and their age, and they don't meet on any of those criteria. Like, what are what are these people doing? Like, who is this quack?

SPEAKER_02 18:18

Yeah, yeah.

SPEAKER_00 18:18

And then I realize someone educates me, like, hey, like there's actually good data that reducing the dose at a certain point, once this is a remote DBT, is actually shown to be have not significant worsening of outcomes and also some reduced risk in bleeding, obviously. They're constantly on the list. And it's another one of those things that it's like any medicine, it's just like easy to ignore and not pay attention to as a hospitalist. And then there's also the question of like what is our role as a hospitalist in the home eds and what they're doing. But I tell them like I'm doing this, and using the hospitalization as a touch point to to make a change.

SPEAKER_01 19:00

Yeah.

SPEAKER_00 19:01

Because a lot of these patients, like, you know, maybe they follow up, but maybe they don't have great follow-up. And this is a time that they're having a lot of minds and a lot of hands on them and an opportunity for us to like do something that might have a better outcome for them.

SPEAKER_01 19:15

I actually texted one of my friends who works in family medicine outpatient, and I was like, if we did this in the hospital for one of your patients, would you be mad? She's like, she's like, no. She's like, I absolutely not. Like we only get 30 minutes with them. We're a lot of times treating a lot of disease states. I don't think it crosses their minds as much as we think it does either, you know? So I think that my NM1 said she was fine.

SPEAKER_00 19:39

So I was interested when you said this because I was largely unaware of this 2013 New England Journal trial that was way back, the Amplify trial.

SPEAKER_01 19:49

Extension, yeah.

SPEAKER_00 19:50

A big randomized trial looked at over 2,000 patients. And this was six to twelve months after anticoagulation for acute phenotheromboembolism, and it compared stopping to 2.5 milligrams of a pixabam BID to 5 milligrams of a pixabam BID. Looking at recurrent clot, if you continued some anticoagulation, you did better than no anticoagulation. In the placebo group, they had 8.8% had another clot. 2.5 milligrams of a pixaban, 1.7% had a recurrent clot. 5 milligrams of pixaban, 1.7% had a recurrent clot. Exactly the same. And then there's been continued other new trials since this. There was the high pro trial from 2025, another randomized controlled trial. It compared placebo to continuing a pixaban at a reduced dose, and this one showed clinically relevant reduction in non-major bleeding, where continuing the 2.5 milligrams of pixaban, 4.8% risk of bleed versus 1.7% risk of a clinically significant bleeding. Then there's also APICAT, another 2025 trial, New England Journal of Medicine, non-inferiority randomized control trial that showed non-inferiority when comparing 2.5 milligrams of a pixaban to 5 milligrams of a pixaban, non-inferior for clots, and specifically in people who had malignancy, a huge risk factor. And we're seeing that a lower dose of pixaban is even safe in these folks. And this is uh looking at folks that had completed six months of therapy. So after six months of epixaban, full dose five milligrams with the initial loading dose in cancer patients went down to 2.5 milligrams. Non inferior. So looking at clinically relevant bleeding in APICAT, 12.1% of the reduced dose 2.5 group, 2.5 milligram epixaban group, 15%. In the full dose, five milligram of pixibang group. Hazard ratio 0.75, statistically significant. So non-inferior for clots, superior for less bleeding, and high recurrence of clot folks that the cancer patients. So finally there was Renault and it shot for the moon. It was a 2025 trial looking for non-inferiority and reducing either a pixaban or riveroxaban in high recurrent clot risk folks, and it failed to show non-inferiority. But importantly, it didn't just look at a pixaban like these other trials we've talked about. And then also it showed a stignific in major bleeding in the major and clinically relevant bleeding in the reduced dose group versus the full dose group. And so 9.9% risk of major and clinically relevant bleeding in the reduced dose group versus 15.2% in the full dose group, hazard ratio 0.6 clinically significant. They also looked at mortality numbers and didn't show a statistically significant difference, but the mortality, there was a difference in mortality there. And so in the full dose group, mortality 6.1%, the reduced dose dose group 4.3%. The hazard ratio was 0.6. It did cross one at 0.44 to 1.03. This is the kind of thing and fits with the a theme we're seeing a lot in anticoagulation in general, and that a lot of times like less is more than doing and it's similar similar to what we're seeing in like cutting off aspirin if you've got someone with coronary artery disease and AFib, some more recent data. A lot of times we're just saying that we don't need to a little bit is good. A lot isn't necessarily better.

SPEAKER_01 23:57

Correct. Yeah.

SPEAKER_00 23:59

And again, to be clear, obviously this is after you've treated, you've treated the acute VTE. This isn't what you're doing from the outset. This isn't changing the protocol for how you, you know, load and start them on full dose DOAC at the beginning, but it is six to twelve months out, depending on the study. But most of these are uh six months out, you can reduce the dose.

SPEAKER_01 24:20

Yeah.

unknown 24:21

Yeah.

SPEAKER_01 24:21

I think it's something I'll, again, it's not something that I've gone out of my way to bring up either, you know. But I think with all this evidence, I think I'll start pushing for it more. Um I feel like the only times we talk about it is when there's clinically relevant bleeding. And then like, maybe if we restart, let's do a lower dose. But otherwise, I feel like it's just kind of like there's only so much you can think about on a patient, but this could make a big difference.

SPEAKER_00 24:39

Yeah. Wouldn't it be nice if we did it before there was the clinically relevant bleeding? All right. And then give me your last one.

SPEAKER_01 24:47

Yeah, I think that my third recommendation is the AMPC bugs and recognizing them and then changing, potentially changing their antibiotics to cepipeme to be more aggressive in those bugs that are at high risk for AMPC production. I think that my experience, hospitalists and clinicians are super aware of ESBL, AMPC, because we can't formally put a label on it because we can't test for a gene. I think sometimes it gets forgotten about.

SPEAKER_00 25:10

I'm certainly guilty of just not paying nearly as much attention. Yeah. Okay. And a quick refresher, just so you recall, AMP C is a specific inducible chromosomal beta-lactomase, which make them resistant to specific antibiotics. And these antibiotics specifically that are clinically significant here are ceftriaxone and piperocillin, the major component of bactrum hypocillantase back down. So a big thing here is the IDSA guidelines were really helpful. These were the guidelines for treatment of antimicrobial resistance and gram-negative infections. And they told us that really clinically we need to be thinking about three specific bugs we see. So these three bacteria that they specifically point out. I'm going to go, you know, pronouncing full names of microbes here. So let's see how it goes. Oh, you want to do it? I mean, I don't care. Good.

SPEAKER_01 26:10

The first one would be enterobacter cloicia, citrobacter frondi. I think is put it before us here.

SPEAKER_00 26:17

I was going to call it plume dye. This is so much.

SPEAKER_01 26:20

Yeah, yeah. And then clubs yellow erogenes.

SPEAKER_00 26:23

Yes. Perfectly. And remind me, so we should be, if we get any of these organisms or think we have in these organisms, we should just be empirically having them on cefopeme until we know, you think?

SPEAKER_01 26:33

Well, that's that's one of the common confusions. So it's an inducible resistance. So you get you get susceptibilities that say it's sensitive to ceftraxone. So like, why wouldn't you use ceftraxone? And then there's like this like small disclaimer at the bottom saying that use of a third-generation cephalous borne may induce resistance. But at the bottom, and I don't think everyone looks at it and like doesn't say don't use it.

SPEAKER_02 26:53

Right.

SPEAKER_01 26:54

You know? So I I feel like the the sensitivity report is reassuring for a lot of people, but you really can't use it because it can there's no way to check to see if it's an AMT producer and it if it would induce its resistance. So really for any invasive infection, any infection ever other than an uncomplicated UTI, cepipheme is what's recommended. Yeah.

SPEAKER_00 27:13

That's awesome. I think I'm gonna be a better clinician based on our conversation.

SPEAKER_01 27:18

I think I really enjoy working with hospitalists. And I think you like you said, like I said earlier, you guys get like the vast majority of things right, and we're just happy to help when we can.

SPEAKER_00 27:25

I'll tell you. Best things about practicing medicine, anytime that you're working closely with a a clinical pharmacist, you realize like how helpful that is. Like almost just if nothing else, just like having another intelligent person who knows what's going on to bounce ideas off of and being able to like sit down with them and talk through your patient list is such a luxury.

SPEAKER_02 27:47

Yeah.

SPEAKER_00 27:47

Not something that we have all the time, something that I know a lot of other people don't have access to, but something that is makes medicine more fun and I think makes makes patient care better. And I advocate for every institution to, you know, hire enough pharmacists that we can that we can do this on uh all the service all the time. All right, so my four takeaways from our conversation. First, phenobarbital does not have to be an ED or ICU only med for alcohol withdrawal, but the evidence we talked about today supports a structured protocolized approach to use phenobarbital on the floor that was found to be safe in this limited observational before and after study, and also did show indications of improvement in length of stay and amount of time on treatment for alcohol withdrawal. Second, steroids alone are not an automatic reason to add a PPI. The evidence that steroids cause increased risk of GI issues is spotty at best, particularly in ambulatory patients. And the evidence indicated that there was not a benefit when you put a patient on a PPI or phomotidine. So second guess that anytime you see that recommendation and really look at your patient and think, what are their risk factors? Third, know the organisms that the IDSA guidelines recommend not using piperacillin or ceftriaxone when they say they're susceptible because of inducible AMP C. And those are again specifically enterobacter cloacae, plebsiella, erogenous, and citrobacter. We want with frondide. Frondi. Don't just trust that it's susceptible to ceftriaxone. You need to be escalating cared to something like cepapema or carbon pinum. And then finally, don't let the epixaban five milligrams twice a day live on your patient's chart forever for someone who had an acute DVT six months, a year, multiple years ago. Look at them, make sure they really have a reason to be on that dose of anticoagulation. And if it's really just for VTE, they probably do not. And I embolden everyone to look at their patients and consider can this patient drop down to a lower dose that could potentially reduce the risk of uh bleeding. Well, thanks again, Lindsay, for joining me and giving us a little bit of a pharmacist reality check.

SPEAKER_01 30:19

This was fun.

SPEAKER_00 30:20

Well, for the audience, links to the studies we discussed can be found in the show notes or via our email lists. And if you got something after this episode, send it to one hospitalist who you think could use a little pharmacist gentle guidance of their own. I'm Mason Turner, and this has been Inpatient Update.