IM Guideline Updates — 2023–2025 Archive

Acute coronary syndromes (ACS) — new in 2025

• Radial first: radial access is emphasized to reduce mortality.
• Lipid management: high-intensity statin plus early ezetimibe or a PCSK9 inhibitor if LDL-C ≥70 mg/dL. A non-statin is reasonable if LDL is 55–69 mg/dL.
• Beta-blockers: routine long-term use beyond 1 year post-MI is not recommended if LVEF is >50%.

Guideline: 2025 ACS guideline

Primary stroke prevention (2024)

GLP-1 receptor agonists: now a Class 1 recommendation for primary stroke prevention in patients with diabetes and high ASCVD risk.

Guideline: 2024 stroke guideline

Cardio-Renal-Metabolic (CRM) syndrome (2023)

A major new framework: a unified staging system (Stages 0–4) linking metabolic risk factors, CKD, and cardiovascular disease. It emphasizes early intervention with SGLT2 inhibitors, GLP-1 receptor agonists, and finerenone.

Guideline: CRM guideline

Type 2 diabetes management

• First-line therapy: a GLP-1 receptor agonist (or tirzepatide) is preferred with ASCVD, heart failure, or CKD. An SGLT2 inhibitor is preferred if heart failure or CKD is dominant.
• A1c targets: <7% for most patients; <8% for limited life expectancy or high hypoglycemia risk.
• Weight management: prioritize agents with weight-loss benefits (GLP-1 receptor agonists, SGLT2 inhibitors, tirzepatide).

Guideline: ADA Standards of Care 2025

Thyroid nodules (2024)

AI-TIRADS: molecular testing (Afirma, ThyroSeq) is clarified for Bethesda III/IV nodules. Active surveillance is more accepted for low-risk microcarcinomas.

Guideline: ATA guidelines

MASLD (formerly NAFLD) — AASLD 2023

• Nomenclature: NAFLD → MASLD, and NASH → MASH. Diagnosis requires ≥1 metabolic risk factor.
• Pharmacotherapy: resmetirom (FDA approved March 2024) for MASH with fibrosis.
• Screening: use FIB-4 for risk stratification; elevated scores warrant hepatology referral.

Guideline: AASLD MASLD guidance

Colorectal cancer screening

Start at age 45: average-risk screening now starts at 45 (USPSTF, ACS, ACG). Colonoscopy, FIT, or stool DNA are acceptable options.

Guideline: USPSTF recommendation

Adult immunizations — CDC 2024

• RSV vaccine: recommended for adults ≥75, or ≥60 with risk factors.
• Pneumococcal: PCV20 alone, or PCV15 plus PPSV23, for vaccine-naïve adults ≥65 or those with risk factors.
• Shingles: recombinant zoster vaccine (RZV) at age 50+, now also recommended for immunocompromised adults ≥19.

Guideline: CDC adult immunization schedule

Antibiotic stewardship

• UTI: nitrofurantoin or TMP-SMX is first-line for uncomplicated cystitis; fluoroquinolones are reserved.
• CAP: 5-day courses are often sufficient (IDSA). High-dose amoxicillin or doxycycline for outpatient CAP.
• SSTI: 5–7 days for uncomplicated cellulitis. I&D alone is often sufficient for small abscesses.

Guideline: IDSA CAP guideline

COPD management — GOLD 2025

• Initial therapy: a LABA/LAMA combination is preferred for most symptomatic patients.
• Triple therapy: LABA/LAMA/ICS for patients with eosinophils ≥300 or frequent exacerbations.
• Biologics: dupilumab is now approved for COPD with T2 inflammation (eosinophils ≥300).

Guideline: GOLD 2025 report

Asthma (GINA 2024)

• No SABA-only: SABA-only treatment is no longer recommended. Use ICS-formoterol as needed for mild asthma (Track 1).
• Biologics: expanded access for severe asthma (tezepelumab for all phenotypes).

Guideline: GINA 2024 report

Rheumatoid arthritis — ACR 2024

• Treat-to-target: methotrexate remains the first-line DMARD. Add a bDMARD or JAK inhibitor if response is inadequate by 3–6 months.
• JAK inhibitors: caution is advised (boxed warning); prefer in patients without major cardiovascular risk or malignancy history.

Guideline: ACR RA guideline

Gout (2023–2024)

• Urate-lowering therapy (ULT) initiation: consider starting during an acute flare (controversial but increasingly accepted). Target uric acid <6 mg/dL.
• Prophylaxis: colchicine or a low-dose NSAID for 3–6 months when starting ULT.

Guideline: ACR gout guideline

VTE management — ASH 2024

• Cancer-associated VTE: LMWH or DOACs (apixaban, rivaroxaban, edoxaban) are preferred. Avoid DOACs in GI/GU malignancies with high bleed risk.
• Duration: extended anticoagulation for unprovoked VTE; weigh the risk and benefit for cancer patients.

Guideline: ASH VTE guidelines

Oncology screening & toxicity

• Breast cancer: screening now starts at age 40 (USPSTF).
• Prostate cancer: screening starts at 45–50 (AUA 2023).
• Immune checkpoint inhibitor (ICI) toxicity (ASCO): grade-based steroid management. Myocarditis requires permanent discontinuation.
• Survivorship: screen for cardiovascular disease (anthracyclines) and psychosocial distress.

Guideline: USPSTF breast cancer screening

Chronic kidney disease (CKD) — KDIGO 2024

• SGLT2 inhibitors: recommended for all CKD patients with heart failure or albuminuria (≥200 mg/g).
• Finerenone: recommended for type 2 diabetes plus CKD with residual albuminuria.
• Diagnostics: use cystatin C with creatinine to confirm eGFR. Use the Kidney Failure Risk Equation (KFRE).

Guideline: KDIGO 2024

Neurology updates

• Alzheimer’s disease: lecanemab or donanemab for mild cognitive impairment with amyloid. Monitor for ARIA.
• Stroke prevention: GLP-1 receptor agonists for primary prevention in patients with diabetes.
• Status epilepticus: a benzodiazepine (0–5 min) → fosphenytoin, valproate, or levetiracetam (5–20 min).
• Myasthenia gravis: new agents include efgartigimod (an FcRn modulator) and eculizumab (a complement inhibitor).

Guidelines: Alzheimer’s appropriate-use criteria · stroke guideline

Geriatrics (2023 Beers criteria)

• Warfarin: non-preferred for atrial fibrillation (DOACs are safer).
• Aspirin: avoid for primary prevention in adults ≥60.
• Sulfonylureas: avoid long-acting agents due to hypoglycemia.

Guideline: Beers criteria update

Palliative medicine

• Integration: refer heart failure and COPD patients based on needs, not just prognosis.
• Opioids: the CDC 2022 clarification confirms the guidelines do not apply to cancer or palliative care.

Guideline: AAHPM guide

Addiction guidelines (2024–2025)

• Stimulant use disorder (ASAM 2024): contingency management is the standard of care. Off-label pharmacotherapy (bupropion, naltrexone) is formalized.
• Benzodiazepine tapering: individualized tapers (5–10% reduction per interval), with recognition of benzodiazepine-induced neurological dysfunction (BIND).
• Opioids: methadone take-homes are more flexible (7 doses in the first 14 days). The X-waiver has been eliminated for buprenorphine.

Guidelines: SAMHSA guidance · ASAM stimulant use disorder guideline

Perioperative & systems care

• Periop anticoagulation: bridging is not recommended for most patients (heparin bridging causes harm).
• Glycemic control: avoid a sliding scale alone. Target 140–180 mg/dL in the ICU.
• Delirium: non-pharmacologic prevention is the standard of care. Avoid routine antipsychotics.

Guideline: perioperative guidelines