2023 Update in ambulatory general internal medicine
===================================================

* Ashley Lim

**To the Editor:** I am writing to express my gratitude for the insightful article “2023 Update in ambulatory general internal medicine” by Jason T. Alexander, MD, and colleagues1 published in the January 2024 issue of the *Journal*.

The authors have succinctly addressed the challenges faced by internists practicing ambulatory medicine, emphasizing the overwhelming nature of managing acute concerns, chronic medical problems, and disease prevention within time-pressure constraints. Their review of 5 significant studies from 2022 and 2023 covering chronic kidney disease, secondary cardiovascular disease, kidney stones, obesity, and lipid management provides valuable insights for the ambulatory medical community.

The discussion about the use of sodium-glucose cotransporter 2 (SGLT-2) inhibitors, specifically empagliflozin, is enlightening. However, as highlighted in the Study of Heart and Kidney Protection With Empagliflozin (EMPA-KIDNEY),2 the benefits were most pronounced in patients with significant albuminuria. Given this, I wonder if there is a need for further clarification on the potential benefits of empagliflozin or alternative SGLT-2 inhibitors in patients without albuminuria.3 A discussion on the potential benefits, risks, and cost, as suggested in the article, would be valuable in guiding clinical decisions.4

Furthermore, the authors provide an excellent overview of diet as secondary prevention, particularly emphasizing the superiority of a Mediterranean diet over a low-fat diet. However, it might be pertinent to explore the feasibility and accessibility of such dietary recommendations for patients, considering cultural and socioeconomic factors. This could aid in tailoring dietary advice to the needs of individual patients.5

In conclusion, the authors have done an admirable job in synthesizing complex medical information for the benefit of practitioners in ambulatory medicine. I appreciate their efforts and hope for continued updates and discussions on the practical application of these findings in clinical practice.

*   Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.

## REFERENCES

1.  Alexander JT, Singh SK, Shah SD, Lambert B, Smith JP. 2023 Update in ambulatory general internal medicine. Cleve Clin J Med 2024; 91(1):40–46. doi:10.3949/ccjm.91a.23056
    
    [Abstract/FREE Full Text](http://www.ccjm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiY2Nqb20iO3M6NToicmVzaWQiO3M6NzoiOTEvMS80MCI7czo0OiJhdG9tIjtzOjIwOiIvY2Nqb20vOTEvMy8xNDUuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  The EMPA-KIDNEY Collaborative Group; Herrington WG, Staplin N, Wanner C, et al. Empagliflozin in patients with chronic kidney disease. N Engl J Med 2023; 388:117–127. doi:10.1056/NEJMoa2204233
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1056/NEJMoa2204233&link_type=DOI) 
    
    [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=36331190&link_type=MED&atom=%2Fccjom%2F91%2F3%2F145.atom) 

3.  Kort E, Jovinge S. Drug repurposing: claiming the full benefit from drug development. Curr Cardiol Rep 2021; 23(6):62. doi:10.1007/s11886-021-01484-5
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1007/s11886-021-01484-5&link_type=DOI) 

4.  Espinoza Suarez NR, LaVecchia CM, Fischer KM, Kamath CC, Brito JP. Impact of cost conversation on decision-making outcomes. Mayo Clin Proc Innov Qual Outcomes 2021; 5(4):802–810. doi:10.1016/j.mayocpiqo.2021.05.006
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1016/j.mayocpiqo.2021.05.006&link_type=DOI) 

5.  Ordovas JM, Ferguson LR, Tai ES, Mathers JC. Personalised nutrition and health. BMJ 2018; 361:bmj.k2173. doi:10.1136/bmj.k2173
    
    [FREE Full Text](http://www.ccjm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjIyOiIzNjEvanVuMTJfMTQvYm1qLmsyMTczIjtzOjQ6ImF0b20iO3M6MjA6Ii9jY2pvbS85MS8zLzE0NS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)