Ayoub Mebarki

[CardiovascularCorner @TrackYourHeart]

Treatment of Essential Hypertension (Adults)

Step 1
◻️ Age <55 years: Start an ACE inhibitor (ACEi) or ARB (ARB if ACEi is not tolerated).
◻️ Age ≥55 years or Black African/Black Caribbean ethnicity: Start a calcium channel blocker (CCB).

Step 2
◼️ACEi/ARB + CCB
◼️ If a CCB is not tolerated, use a thiazide-like diuretic instead.

Step 3
◻️ ACEi/ARB + CCB + thiazide-like diuretic

Step 4 (Resistant Hypertension)
◻️ If serum potassium is ≤4.5 mmol/L: Add low-dose spironolactone.
◻️ If serum potassium is >4.5 mmol/L: Consider an alpha-blocker or beta-blocker, or seek specialist advice.

Key point: Use either an ACE inhibitor or an ARB, never both together.

Reference: NICE Guideline NG136: Hypertension in adults: diagnosis and management (updated February 2026).

[Edgar V. Lerma 🇵🇭 @edgarvlermamd]

Urea vs. tolvaptan for hospitalized patients with SIADH ca. 2026 from @NDTsocial
#Nephpearls

👉🏼 https://t.co/22e5Cwt062

[Edgar V. Lerma 🇵🇭 @edgarvlermamd]

Consensus Recommendation: Real World Insights on Attitudes and Treatment of Hyperkalemia ca. 2026 from @MayoProceedings @RPANephrology @GarySingerMD
#Nephpearls

👉 https://t.co/qBWATmz0bL

[Edgar V. Lerma 🇵🇭 @edgarvlermamd]

DKA in Patients on Dialysis and Anuria: Pathophysiology, Pearls, and Pitfalls from @RenalFellowNtwk @simonjsmiths @jamiekwillows #Nephpearls #PathophysiologyPearls

https://t.co/BwaK9nr307

[Sayed S Rahman @SayedSRahman1]

BANFF CLASSIFICATION OF RENAL ALLOGRAFT BIOPSY 2022.
Simplified
PART 1/2

#BANFF

[KIReports @KIReports]

3/Tunneled HD-CVC has a Dacron cuff:
➡️allows tissue integration to anchor the catheter
➡️protects against pericatheter bacterial entry. Hence, lesser CRBSI with tunneled vs non-tunneled (1.6 vs. 4.8 per 1000 catheter days; 95% CI 1.5–1.7 and 4.2– 5.3, respectively)

[Jasmine Sethi @JasmineNephro]

✋Prevent CLABSI/CRBSI

🔥Interesting @NEJM read

1️⃣Hand hygiene🧴🤲

2️⃣Barrier precaution 🧢😷🥼

3️⃣Skin prep with 2%chlorhexidine 🧪
and bath 🛀

4️⃣Chlorhexidine dressing🩹

5️⃣Antibiotic impreg catheter/hubs/caps
6️⃣Site-femoral⬆️CRBSI, Subclavian⬇️

➡️https://t.co/EitivsIM6q

[Sayed S Rahman @SayedSRahman1]

ALPORT :
Renaming an extended Clinical Spectrum to promote a comprehensive understanding of the condition.

https://t.co/e3FQB71A2W
https://t.co/kVjFTbSnbX

[Dr Raza Ali Akbar @aliraza4]

Priyam.
I'm so glad you raised this vital case. Astute clinical approach is needed in managing the acute Dyspnea patients. Hence my very first series on MedEd YouTube channel is on 'Acute Dyspnea'. Flagging one of the videos on first 15-30 minutes of Acute Dyspnea assessment. Hope it inspires and helps the trainees globally. Please check my channel and subscribe for more exciting content I'm Internal Medicine.
#MedEd
#InternalMedicine
#MedTwitter

https://t.co/TQQmRE0OvC

[Sociedad de Medicina de Emergencias de la Laguna @SOMELaguna]

Estrategias de Manejo de la Insuficiencia Cardíaca en Enfermedad Renal Crónica🫀🫘

🔰📚Biomedicines 2026

https://t.co/DzQLoU7oYB

Enlace a Articulo Completo👇🏻✅🆓
https://t.co/rPEDXf65lm

[𝒂𝒃𝒐𝒖𝒕 𝒑𝒉𝒂𝒓𝒎𝒂𝒄𝒚💊 @aboutpharmac]

Prefered diuretics in CKD

[Scott Isaacs @scottisaacsmd]

Too many people are put on lifelong levothyroxine for borderline TSH elevations or nonspecific symptoms, then never reassessed, yet trials show little benefit for most with subclinical hypothyroidism and risks from overtreatment like a-fib and bone loss. We need to normalize “deprescribing” thyroid hormone when it was started for borderline labs, low doses, or no clear diagnosis, and routinely see if patients can come off instead of renewing forever.
https://t.co/7OxpBMhy0u

[Dr.Mukesh , MD , DM @dr_immuno29]

🧵 Steroids in Rheumatology: Friend, Foe… or Fine Balance?
From cornerstone therapy to cautious precision use

📍 Published in The Lancet Rheumatology (2026)
📄 DOI: 10.1016/S2665-9913(26)00072-X

⸻

• Still a cornerstone → rapid, potent anti-inflammatory effect
• But ⚠️ cumulative toxicity = major concern

⸻

• 🎯 Guideline consensus:
→ Use as short-term bridge
→ Lowest effective dose
→ Taper ≤5 mg/day within months
→ Stop if possible

⸻

• ❗Reality check:
→ Chronic use (>6 months) very common
→ ~40–50% pts remain on steroids in real-world cohorts

⸻

• 🔑 Why mismatch?
→ Difficult-to-treat disease
→ Flares on tapering
→ Limited access to biologics
→ Physician/patient reluctance
→ Implementation gaps

⸻

• ⚖️ Emerging concept:
→ Very low dose (<5 mg/day) may be acceptable in selected pts
→ Requires strict monitoring

⸻

• 📊 Safety signals (≤5 mg/day):
→ ❌ No ↑ mortality / CV risk (most data)
→ ❌ No major osteoporosis signal
→ ⚠️ Mild infections ↑
→ ⚠️ Disease activity = key confounder

⸻

• 💡 Strategy shift:
→ Combine DMARD + biologic + very low-dose GC
→ May overcome “ceiling effect” in RA
→ Better flare control, function, structure

⸻

• 🔥 Disease-specific pearls:
→ RA/SLE: bridge → taper → stop
→ SLE severe: pulses → rapid taper
→ PMR: longer use but gradual taper essential

⸻

• ⚠️ Key risk paradox:
→ Both steroids + inflammation → CV, infection, osteoporosis
→ Goal = control disease + minimize steroids

⸻

• 🧠 Take-home:
→ “As much as necessary, as little as possible”
→ Aim: steroid-free remission
→ If not → ≤5 mg/day pragmatic compromise

⸻

#LancetRheumatology #Glucocorticoids #Steroids #RheumatoidArthritis #SLE #PMR #MedTwitter #EvidenceBasedMedicine

[Kajaree Giri @KajareeG]

🎉KDIGO updates on Management of CKD Anemia made easy at #ISNWCN
🩸Adult patients with CKDG5HD, initiate iron therapy if ferritin &lt; 500 and TSAT &lt; 30%
#ISNWCN

[Gopambuj Singh Rathod @IamGopambuj]

Confused about osteoporosis drugs in CKD?
👉 Low PTH = build bone → Teriparatide
👉 Any CKD = use safely → Denosumab (watch Ca!)
👉 Early CKD only → Bisphosphonates
Simple rule: Turnover guides therapy
#GSR #BuddingNephros #Nephrology #CKD

[ERM @Owner_X429]

Anemia 2026

[CME INDIA @CMEINDIA1]

🚨 Resistant Hypertension: From “Apparent” to “True” — Precision Matters (JAMA 2026)

🔬 Definition & Epidemiology — Not All Resistant HTN is Real

Apparent resistant HTN = BP ≥130/80 mm Hg despite ≥3 drugs (ACEi/ARB + CCB + thiazide) at optimal doses

~20% of treated hypertensives fall into this category

BUT → True resistant HTN ≈10% only after exclusion of:

White-coat effect (~37.5%)

Nonadherence (~50%)

Secondary causes (~5–25%)

👉 Clinical message: Most “resistant HTN” is pseudo-resistant → diagnosis refinement is critical

🧠 Stepwise Diagnostic Algorithm (High-Yield Clinical Thinking)

1️⃣ Exclude White-Coat Effect

Home BP <130/80 OR ABPM <125/75 mm Hg
➡️ Continue monitoring, no overtreatment

2️⃣ Assess Adherence (Underrated Step)

Use refill data / drug assays

Address:

Cost barriers

Adverse effects

Cognitive issues

3️⃣ Screen Secondary Causes

Primary aldosteronism (commonest)

CKD, OSA, obesity, drugs (NSAIDs, SNRIs, cocaine)

👉 Only after this → TRUE resistant HTN confirmed

⚠️ Why It Matters (Prognostic Impact)

↑ Cardiovascular mortality risk (absolute ↑ ~10% over 5–10 yrs)

Strong association with:

Diabetes

CKD

Obesity

Sleep apnea

🧬 Therapeutic Strategy — CME India Algorithmic Pearls

🔹 Step 1: Lifestyle (Foundation Therapy)

Sodium <1500 mg/day

Weight loss + exercise ≥150 min/week

Avoid alcohol, offending drugs

Treat OSA

👉 Often neglected but high-yield in India

🔹 Step 2: Optimize Triple Therapy

Prefer single-pill combinations (↑ adherence, ↓ SBP ~4 mmHg)

Diuretic optimization:

Chlorthalidone > thiazide (especially CKD)

Add loop diuretic if eGFR <30

🔹 Step 3: Add Mineralocorticoid Receptor Antagonist (MRA) — ⭐ GAME CHANGER

Spironolactone 25–50 mg/day

↓ Office SBP: ~13 mmHg

↓ Ambulatory SBP: ~8 mmHg

Criteria:

eGFR ≥45 ml/min

K⁺ ≤4.5 mmol/L

👉 Most effective add-on therapy in resistant HTN

🔹 If Spironolactone Intolerance

Amiloride (non-inferior)

Eplerenone (less potent, fewer endocrine effects)

🔹 Step 4: Sequential Add-ons

β-blockers

α1-blockers (doxazosin)

Central agents (clonidine)

Non-DHP CCB

Vasodilators

Aprocitentan (dual endothelin antagonist — emerging option)

🔹 Step 5: Device Therapy

Renal denervation

↓ Ambulatory SBP ~4.4 mmHg

↓ Office SBP ~6.6 mmHg
👉 For selected refractory cases

💊 Drug Hierarchy (Practical Take-Home)

👉 Best Add-On:
✔️ Spironolactone > all others

👉 Alternatives:
✔️ Amiloride ≈ spironolactone
✔️ Eplerenone (safer endocrine profile)

👉 Less Effective / Add-on:
β-blockers, α-blockers, clonidine

👉 New Kid:
Aprocitentan (modest effect, fluid retention risk)

⚠️ Adverse Effect Awareness

Spironolactone:

Hyperkalemia (3–5%)

Gynecomastia (~5–9%)

Clonidine:

Rebound HTN

α-blockers:

Orthostatic hypotension

🎯 CME INDIA CLINICAL PEARLS

🔴 “Resistant HTN is often diagnostic failure, not therapeutic failure”

🔴 “Half of resistant HTN = nonadherence → always check before escalating”

🔴 “Chlorthalidone + Spironolactone = backbone of resistant HTN therapy”

🔴 “Primary aldosteronism is underdiagnosed → think beyond essential HTN”

🔴 “Single-pill combinations are not convenience—they are outcome modifiers”

🔴 “Renal denervation: modest BP fall but useful in selected refractory cases”

📚 Key Reference (Journal Format)

Carey RM, et al. Resistant Hypertension: Diagnosis and Management. JAMA. 2026; doi:10.1001/jama.2026.2846682
https://t.co/QIUmgZWALJ

[Aravind Palraj @Rheumat_Aravind]

🧵 AKI on Rounds — Prerenal, ATN, GN, or Obstruction?

Creatinine jumped.
Now what?
Here’s a 60-second roadmap to classify AKI fast and act early. 👇
@DurgaPrasannaM1 @IhabFathiSulima @DrAkhilX @CelestinoGutirr @arvindcanchi @JasmineNephro @EMJNephrology @Wagner_Nephro #MedTwitter #RheumTwitter #NephoTwitter

[Sayed S Rahman @SayedSRahman1]

Rituximab dosing and management for Nephrotic syndrome .

[nervemed @nervemed]

�� Emergency Drugs & Doses

1. Adrenaline
🔹Use: Anaphylaxis
🔹Dose: 0.3–0.5 mg IM
🔹Concentration: 1:1000

2. Atropine
🔹Use: Bradycardia
🔹Dose: 1 mg IV
🔹Repeat: Every 3–5 minutes
🔹Max dose: 3 mg

3. Adenosine
🔹Use: SVT
🔹Initial dose: 6 mg rapid IV
🔹Then: 12 mg if needed

4. Amiodarone
🔹Use: Ventricular Tachycardia
🔹Dose: 150 mg IV
🔹Infusion time: Over 10 minutes

5. Calcium Gluconate
🔹Use: Hyperkalemia
🔹Dose: 10 mL of 10% IV
🔹Infusion time: Over 2–5 minutes

6. tPA
🔹Use: Ischemic Stroke
🔹Dose: 0.9 mg/kg IV
🔹Max dose: 90 mg
🔹Administration: 10% bolus, rest over 60 minutes

7. Insulin
🔹Use: DKA
🔹Dose: 0.1 U/kg/hr IV infusion

8. Labetalol
🔹Use: Hypertensive Emergency
🔹Dose: 20 mg IV bolus
🔹Note: May repeat / escalate

9. Lorazepam
🔹Use: Seizure
🔹Dose: 4 mg IV
🔹Repeat: May repeat once

10. Furosemide
🔹Use: Pulmonary Edema
🔹Dose: 20–40 mg IV