Episode 246 -- January 2026 -- Part 2 AFP: American Family Physician

Summary

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AFP: American Family Physician Podcast

Episode 246 – January 2026, Part 2
Date: January 30, 2026
Contributing Editor: Dr. Steven Brown
Participants: Jake Anderson, Austin Cotter, Emily Eisenberg

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Episode Overview

This episode explores practical updates and clinical pearls from January’s American Family Physician issue. The hosts dissect evidence-based approaches for managing endometriosis pain, HIV-associated complications, the use of GLP-1 receptor agonists for adolescent obesity, deprescribing antihypertensives in older adults, vertebral compression fractures, and optimal dosing of sublingual buprenorphine for opioid use disorder. Throughout, they maintain a casual, collegial tone and engage in lively, evidence-focused discussions.

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Key Discussion Points and Insights

1. Endometriosis-Associated Pain (00:36–03:30)

• Meta-Analysis Covered: 31 RCTs, 21 interventions for histologically or radiographically diagnosed endometriosis with ≥6 months of pelvic pain.
• Findings:
  • Four regimens superior to placebo; none clearly better than others:
    1. Leuprolide
    2. Dienogest (brand-dependent availability)
    3. Combined Oral Contraceptives (COCs)
    4. COC + Leuprolide
  • NSAIDs notably not included in the analysis.
• Caveats: Many studies had high risk of bias due to inadequate blinding.
• Notable moment:
  • [03:15] Emily offers a legitimate "poem":

    “Studies of endometrial pain all seeking what will make the ache wane. But bias was there as masking was rare. Still, leuprolide and COCS reign.” — Emily Eisenberg (03:15)

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2. HIV-Associated Complications: A Systems-Based Approach (03:31–07:37)

• Theme: With improved longevity, the spectrum of HIV care encompasses chronic, multi-organ diseases.
• Key Systems and Recommendations:
  • Metabolic/Endocrine: Cardiovascular risk is heightened.
    • [03:56] “ACC/AHA guidelines say to grab a lipid panel at diagnosis and statins reduce major cardiovascular events in patients aged 40 to 75 at low to moderate risk.” — Austin Cotter (03:56)
  • Glycemic Control: Use fasting glucose over A1C for monitoring (A1C may be misleading).
  • Body Weight: Weight gain common, but ART should not be switched for weight gain alone; focus on lifestyle.
  • Bone Health: Fracture risk is 10–50% higher; DEXA scans recommended for certain populations.
  • Neurocognitive: 30–50% have cognitive impairment.
    • Diagnosis is clinical, supported by neurocognitive testing.
  • Peripheral Neuropathy: Managed with gabapentin, capsaicin patches, exercise, and avoiding neurotoxic ART.
  • Renal: CKD common; annual BMP and urine albumin/creatinine advised.
  • Sexual Health: “U=U” (Undetectable = Untransmittable) emphasized.
    • Doxycycline PEP for eligible men who have sex with men and some trans women.
    • Emphasize HPV vaccination.
  • Pulmonary: Higher rates of asthma, COPD, pulmonary HTN, and interstitial lung disease.
  • GI/Hepatic: Increased cancer risk, liver disease, and gastrointestinal symptoms.
  • Musculoskeletal: Arthralgia common; brief steroids sometimes useful.
  • Skin/Hematologic: Frequent infections, cytopenias, and increased malignancy risk.
• Core Pearl:

  “HIV care does not stop at viral suppression. It's a full body approach.” — Jake Anderson (07:37)

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3. GLP-1 Receptor Agonists for Obesity in Adolescents (07:37–12:20)

• Case: 16-year-old with BMI 40, failed lifestyle/Orlistat, curious about semaglutide (WeGovy).
• Evidence:
  • Both semaglutide (WeGovy) and liraglutide (Saxenda) FDA approved for adolescents ≥12 with BMI ≥95th percentile.
  • BMI reduction: Semaglutide led to a 16% reduction over 68 weeks; liraglutide showed a 7% reduction in younger children (6–12) per smaller trial.
  • Concerns:
    • Long-term health outcomes unknown.
    • Discontinuation leads to significant weight regain—lifelong therapy likely needed.
    • Access: Most private insurance does not cover; cost >$1,000/month.
    • Notable sociodemographic disparities in access.
    • Risks of seeking unregulated/black market meds online.
    • Psychological impact: High risk for body dissatisfaction, disordered eating; medication may mask or worsen restrictive eating habits.
• Clinical Guidance:
  • Primary care providers must be adept at holistic obesity care, including both behavioral and pharmacologic interventions.
  • Ongoing mental health screening and advocacy essential.
• Quote:

  “It’s more complicated than just sending in a prescription for Wegovy. We have to have a very critical lens... significant questions about equity of access, lifelong need and financial burden.” — Jake Anderson (09:11)

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4. Discontinuing Antihypertensives in Adults 50+ (12:46–14:41)

• Core Question: Can antihypertensives be safely stopped in adults ≥50?
• Cochrane Review Findings:
  • Stopping meds raised BP by 10 mmHg systolic, 3–4 mmHg diastolic.
  • No significant increase in death, stroke, MI, or hospitalization (Strength: B, patient-oriented evidence; mostly for primary prevention).
  • Caveats: Small trials, older methods, limited blinding/follow-up.
  • Beers Criteria and STOP-START Criteria support cautious deprescribing for adults over 65.
• Key Reminder:

  “Deprescribing antihypertensives can be safe in the right patient. Just do it on purpose, not because someone read half a headline on Facebook.” — Jake Anderson (14:41)

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5. Vertebral Compression Fractures (14:59–18:11)

• Epidemiology: Over 500,000 cases/year in the U.S., often the first sign of osteoporosis.
• Risk Factors: Same as osteoporosis; obesity is protective due to increased bone mass.
• Mechanism: Axial load exceeds vertebral strength, mainly anterior column (stable injury).
• Clinical Presentation:
  • 2/3 asymptomatic, found incidentally.
  • Acute pain usually resolves by 12 months; concern for chronic pain/disability.
• Evaluation:
  • Visual inspection (kyphosis/lordosis), palpation, neurologic exam, provocative tests (e.g., closed fist percussion).
  • Imaging: Start with X-rays (≥20% height loss diagnostic); escalate to CT/MRI if suspicion remains or to clarify/characterize fractures.
• Management:
  • Conservative first: NSAIDs/Tylenol, antiosteoporotic medications (bisphosphonates, calcitonin, teriparatide), Vitamin D/calcium.
  • Rehab: Begin after 2 weeks, multiple sessions.
  • Invasive procedures (vertebroplasty/kyphoplasty) if no improvement in 4–10 weeks.
• Prevention:
  • Focused on osteoporosis prevention (screening, lifestyle, supplements).
• Quote:

  “Prevention of vertebral compression fractures centers on prevention of osteoporosis.” — Austin Cotter (18:11)

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6. Optimal Dose of Sublingual Buprenorphine for Opioid Use Disorder (18:32–20:34)

• Clinical Inquiry: What maintenance dose best reduces relapse/mortality?
• Evidence Summary:
  • Higher doses (24–40mg/day):
    • Better retention in treatment vs. 16mg.
    • Lower overdose-related and all-cause mortality (NNT = 167 & 334, respectively).
    • Longer time to ED visits/hospital admissions.
    • Supported by large U.S. and international data sets.
  • Guidelines (ASAM 2023): Recommend 16–32mg/day, published prior to current larger studies.
• Clinical Takeaway:
  • “Higher doses do seem to improve retention and treatment and are associated with both lower overdose related mortality and all cause mortality.” — Austin Cotter (19:08)

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Notable Quotes & Memorable Moments

• On Endometriosis Research:

  “Still, leuprolide and COCS reign.” — Emily Eisenberg, poetic summary (03:15)

• On Complexity of GLP-1 Agonist Therapy in Adolescents:

  “It's more complicated than just sending in a prescription for Wegovy...” — Jake Anderson (09:11)

• On Deprescribing Antihypertensives:

  “Just do it on purpose, not because someone read half a headline on Facebook.” — Jake Anderson (14:41)

• On HIV as a Multisystem Disease:

  “HIV care does not stop at viral suppression. It's a full body approach.” — Jake Anderson (07:37)

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Timestamps for Major Segments

• Endometriosis Pain: 01:36–03:30
• HIV Multisystem Complications: 03:31–07:37
• GLP-1 Agonists in Adolescent Obesity: 07:37–12:20
• Deprescribing Antihypertensives: 12:46–14:41
• Vertebral Compression Fractures: 14:59–18:11
• Buprenorphine for Opioid Use Disorder: 18:32–20:34

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Summary Table: Key Clinical Pearls

| Topic | Main Clinical Takeaways | Notable Quotation & Timestamp | |-------------------------------------|-----------------------------------------------------------------------------------------------------|--------------------------------------| | Endometriosis Pain | Leuprolide, dienogest, COCs, and COCs + leuprolide outperform placebo, but none is superior | “Leuprolide and COCS reign.” (03:15) | | HIV Complications | Comprehensive chronic care is required—cardio, renal, bone, neuro, sexual health, etc. | “It's a full body approach.” (07:37) | | GLP-1 Agonists in Adolescents | Effective BMI reduction, but equity, cost, access, psychosocial impacts are key limiting factors | “More complicated than a prescription.” (09:11) | | Deprescribing Antihypertensives | Possible and safe in select adults ≥50 without major comorbidities; minor BP increase expected | “Do it on purpose, not via Facebook.” (14:41) | | Vertebral Compression Fractures | Conservative first; focus on osteoporosis prevention to reduce risk | “Prevention...centers on osteoporosis.” (18:11) | | Sublingual Buprenorphine Dosing | Higher doses (16–40mg) = better retention, lower mortality | “Higher doses...improve retention.” (19:08) |

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Conclusion

This episode delivers practical, up-to-date summaries that cover common yet challenging clinical situations—balancing nuanced evidence discussion with the real-world concerns of family physicians. The hosts’ conversational dynamic makes for an engaging and informative listen, with memorable pearls you can bring right to clinic.

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Transcript

[Podcast Announcer]

The AFP Podcast is brought to you by the American Academy of Family Physicians and by the AFP's board review, Express, Certify, Recertify, or refresh on all family medicine topics. You'll find it all here. More information for the next live event, February 18th through the 21st, [e-mail] bre2026. That's AAFP.org bre2026.

[Jake Anderson]

Welcome to the American Family Physician podcast for part two of the January 2026 issue. I'm Jake.

[Austin Cotter]

I'm Austin.

[Jake Anderson]

And I'm Justin and we are residents and faculty, mostly residents, of the University of Arizona College of Medicine, Phoenix Family Medicine residency programs. Today on the podcast we'll talk about endometriosis associated pain, HIV associated complications, GLP1 receptor agonists for obesity in adolescence, discontinuing antihypertensives in adults 50 years and older, vertebral compression fractures, and sublingual buprenorphine for opioid use disorder.

[Podcast Host/Producer]

The opinions expressed in the podcast are our own and do not represent the opinions of the American Academy of Family Physicians. The editor of American Family Physician or Banner Health do not use this podcast for medical advice. Instead, see your own family doctor for medical care.

[Austin Cotter]

Animation.

[Jake Anderson]

First up, we have a poem, Endometriosis Associated Pain, and it comes to us from Dr. Linda Spear.

[Austin Cotter]

All right guys, to start off this episode, I've got another poem for y'.

[Emily Eisenberg]

All. Does it at least rhyme this time? I feel like every time you bring a poem it's just more medicine.

[Jake Anderson]

Guys, we've gone over this.

[Emily Eisenberg]

Can't it just be poetry?

[Jake Anderson]

This isn't that kind of poem.

[Austin Cotter]

Oh, nope, you're right. More patient oriented evidence that matters. Per our podcast theme, this time reviewing a meta analysis from Kuo et al that set out to answer the question, what treatments are effective for endometriosis related pain?

[Jake Anderson]

And in addition to this not being a rhyming poem, it is important because few articles have compared these treatments head to head.

[Emily Eisenberg]

Fine. Who did they include in their analysis?

[Austin Cotter]

Well, the authors included 31 RCTs that analyzed 21 therapeutic interventions for endometriosis pain. Inclusion criteria included a study population with endometriosis diagnosed on histology or imaging and at least six months of pelvic pain.

[Jake Anderson]

One caveat was that according to the Cochrane Risk of Bias tool, a large number of the included studies had high risk of bias due to unclear or no masking.

[Emily Eisenberg]

Well, what did they find? Did something work for their pain?

[Austin Cotter]

Yes, for the primary outcomes of endometriosis pain four regimens proved superior to placebo, although no single one of these regimens is superior to the others.

[Jake Anderson]

These were number one Leuprolide, number two Dienogest, which is only available as brand name Natasia number three combined oral contraceptives and number four combined oral contraceptives plus Leuprolide. NSAIDs were not included in the meta analysis. Interestingly.

[Emily Eisenberg]

Okay, that's great, but I still want a lowercase poem, so here goes. Studies of endometrial pain all seeking what will make the ache wane. But bias was there as masking was rare. Still, leuprolide and COCS reign.

[Jake Anderson]

Very nice.

[Austin Cotter]

Fantastic.

[Jake Anderson]

Wow. Yep, I'm impressed. Next up, we have a main topic, HIV associated complications, a systems based approach and it comes to us from Dr. Jaques Tran and bot from California and Tennessee.

[Emily Eisenberg]

We've made huge strides in HIV care. People are living longer, which is amazing, but that also means we're seeing a whole spectrum of chronic multi organ complications. So today we're doing the grand tour.

[Austin Cotter]

All right, let's start with metabolic and endocrine issues. Cardiovascular disease and hyperlipidemia are common from both HIV itself and ART ACC AHA guidelines say to grab a lipid panel at Diagnosis and statins reduce major cardiovascular events in patients aged 40 to 75 at low to moderate risk.

[Jake Anderson]

Chronic inflammation also drives insulin resistance, so the American Diabetes association recommends fasting glucose before starting or switching ART again at three to six months and then annually if normal glucose actually beats the A1C here. Since altered red cell turnover can make the A1C test misleading, weight gain comes.

[Emily Eisenberg]

Up a lot too, partly reversal of HIV related catabolism, partly ART side effects. But guidelines don't recommend switching ART just for weight gain, so lifestyle counseling stays the move.

[Austin Cotter]

And don't forget bones. Fracture risk is 10 to 50% higher and happens up to a decade earlier. DEXA scans are recommended for postmenopausal women, men over 50 and younger patients with risk factors.

[Jake Anderson]

Neuropsychiatric complications are also common. About 30 to 50% of people with HIV have neurocognitive impairment from chronic neuroinflammation or ART effects. Diagnosis is clinical and supported by neurocognitive testing.

[Emily Eisenberg]

Peripheral neuropathy hits a similar percentage from viral injury, immune activation, opportunistic infections or again art. Treatment per IDSA guidelines includes gabapentin and capsaicin patches plus exercise in stopping neurotoxic ART when possible.

[Austin Cotter]

Genitourinary wise CKD is common due to diabetes, hypertension and Hepatitis co infection screen patients annually with a BMP in urine albumin to creatinine ratio. Erectile dysfunction still remains common as well, so always ask your patients.

[Jake Anderson]

HIV associated nephropathy is rarer now thanks to art, but some regimens are still nephrotoxic and sexually U u this is real and well supported, meaning undetectable. HIV viral load equals untransmissible.

[Emily Eisenberg]

Sticking with sexual health, syphilis needs longer clinical and serologic follow up up to 24 months. Gonorrhea and chlamydia though are standard of care just like any other patient. But doxycycline post exposure prophylaxis is now recommended for men who have sex with men and transgender women with a bacterial STI in the past year. HPV cancers are also more common, so really emphasize vaccination and screening.

[Austin Cotter]

Pulmonary complications of HIV include higher rates of asthma, copd, pulmonary hypertension, interstitial lung disease and lung cancer. Chronic inflammation and smoking play a role. Anyone with symptoms should get pulmonary function.

[Jake Anderson]

Testing gastrointestinal wise there's higher cancer risk, Kaposi's sarcoma, non Hodgkin's lymphoma and anal cancer. HIV also damages gut immunity, increasing bacterial translocation. ART can cause GI upset and liver injury and HIV increases risk of hepatitis B C and hepatocellular carcinoma.

[Emily Eisenberg]

Treat hepatitis C normally and then for hep B just choose the ART that is active against both viruses.

[Austin Cotter]

Musculoskeletal complications include arthralgia in about a quarter of patients. Short steroid courses can help, but prolonged use of steroids still needs caution.

[Jake Anderson]

Skin complications are common too. Bacterial, viral, fungal and opportunistic infections included everything from cellulitis to molluscum and finally hematologic issues.

[Emily Eisenberg]

We see a lot of cytopenias and a higher malignancy risk, so ongoing monitoring and opportunistic infection prophylaxis are key here.

[Jake Anderson]

So the big pearl here HIV care does not stop at viral suppression. It's a full body approach. We have a curbside consultation GLP1 receptor agonist for obesity in adolescents and it comes to us from a team out of Travis Air Force Base in California and Uniformed Services University of the Health Sciences in Bethesda.

[Austin Cotter]

This curbside consultation considers the case of a 16 year old with a BMI of 40 and associated hypertension and metabolic associated sciatotic liver disease presenting for weight management follow up. This patient had previously been unable to lose weight through intensive health, behavior and lifestyle treatment for six months, so he was started On Orlistat.

[Emily Eisenberg]

He returns today having lost 3kg but with frequent diarrhea. From the orlistat. He has seen TV ads for WeGovy Semaglutide and wonders if this is an option.

[Jake Anderson]

Yeah, good case. It's also a situation that we're seeing more often. We know that obesity in adolescence places patients at higher risk for type 2 diabetes, hypertension, metabolic associated steatotic liver disease, obstructive sleep apnea, depression and peer victimization.

[Austin Cotter]

And unfortunately for adolescents with severe obesity, which is a BMI of 35 or higher, lifestyle interventions have been shown to have limited effectiveness.

[Emily Eisenberg]

So the American Academy of Pediatrics recommends considering pharmacotherapy for adolescents with obesity. But the introduction of potent medications like GLP1 receptor agonists presents a host of complex psychosocial and of course, financial questions that extend beyond clinical efficacy. Right.

[Jake Anderson]

As the authors point out, it's more complicated than just sending in a prescription for Wegovy. We have to have a very critical lens when considering these meds, knowing that there are significant questions about equity of access, lifelong need and financial burden. So let's start with the evidence for GLP1 agonists in this population.

[Austin Cotter]

Well, two GLP1 receptor agonists, semaglutide, named Brand Wegovy and Liraglutide, Namebre and Saxenda are approved by the U.S. food and Drug Administration for treating obesity in adolescents 12 years and older with a BMI at the 95th percentile or higher. Trials have shown significant reduction in BMI with these meds, including a bmi reduction of 16% with semaglutide over a 68 week trial.

[Jake Anderson]

However, long term differences in other health related outcomes in this adolescent population is still under investigation.

[Emily Eisenberg]

Currently, no medications are approved for obesity treatment in children younger than 12. But a randomized control trial of 82 patients 6 to 12 years of age did find that liraglutide resulted in estimated BMI reduction of 7% compared to placebo.

[Jake Anderson]

So, promising options when thinking about BMI reduction. But let's talk more about the long term management questions and the important cost.

[Austin Cotter]

Yeah, discontinuation of semaglutide and and liraglutide is associated with significant weight regain, suggesting obesity may need to be managed as a chronic condition requiring long term, possibly lifelong medication. This needs to be discussed from the beginning when considering these meds.

[Emily Eisenberg]

The cost is prohibitive for many and insurance coverage is often inconsistent. Most private insurers do not cover weight loss medications for adolescents and these medications can exceed $1,000 per month and cost.

[Austin Cotter]

Is only one of the barriers to accessing these meds. Studies in adults reveal disparities in GLP1 receptor agonist use linked to race, income and education level, a concern that likely extends to adolescents. These access barriers exist alongside the danger of patients seeking cheaper, unregulated and potentially counterfeit medications online, which poses serious safety risks.

[Jake Anderson]

What's more, adolescents with obesity are at high risk for depression, anxiety, body dissatisfaction and disordered eating behaviors and GLP1 receptor agonists. While they promote satiety, the effect could inadvertently mask or worsen restrictive eating behaviors.

[Emily Eisenberg]

So a lot to consider here. What should we do?

[Austin Cotter]

Well, first, because access to pediatric weight management specialists varies, primary care clinicians providing care for adolescents should be knowledgeable about behavioral and pharmacologic interventions for obesity.

[Emily Eisenberg]

Physicians can address psychosocial factors, screen for disordered eating behaviors, and of course advocate for patients facing access or coverage issues. The family physician is central to providing holistic care, especially as adolescents transition into adults.

[Austin Cotter]

This involves not only prescribing and monitoring, but also addressing the deeper psychosocial context, screening for mental health and eating disorders, and counseling families on the significant long term commitment, uncertain evidence in financial realities of using GLP1 receptor agonists.

[Jake Anderson]

We'll be back with more AFP Podcast after this.

[Podcast Announcer]

The AFP podcast is brought to you by the American Academy of Family Physicians and by the AAFP Audio app. Listen to clinical and management content from American Family Physician and FPM anywhere and earn CME credits on your schedule. Download now and enhance your family medicine expertise. Download today on the App Store or Google Play Store.

[Jake Anderson]

Moving right along, we have a Cochrane for Clinicians discontinuing antihypertensive Drugs in adults 50 and older and it comes to us from a team out of Baylor College of medicine in Houston, Texas. Drs. Laura Quinte and Sarkar alright, today's clinical question one.

[Emily Eisenberg]

I know a lot of patients and clinicians secretly wonder about can we safely stop antihypertensives in adults over 50 without everything immediately falling apart?

[Austin Cotter]

Well, apparently yes.

[Jake Anderson]

A Cochrane review says discontinuing antihypertensives does bump blood pressure a bit, about 10 systolic and 3 to 4 diastolic, but it doesn't significantly increase death, stroke, MI or hospitalizations.

[Emily Eisenberg]

And that's a strength of Recommendation B based on limited quality but patient oriented evidence. The review looked at six randomized trials with just over a thousand patients. But a very important caveat these were folks on meds for primary prevention, not people with prior mi, heart failure or.

[Austin Cotter]

CKD So, no, we're not yanking meds from somebody with an ejection fraction of 20.

[Jake Anderson]

And reassuringly, there was no increase in all cause, mortality or stroke backed by low certainty evidence. Michigan hospitalization rates also didn't rise, though the evidence there is less robust.

[Emily Eisenberg]

Yeah, the trials had some issues. Small sample sizes, older methodology, limited blinding and incomplete follow up, among other things.

[Austin Cotter]

Plus, event rates are low, which means wide confidence intervals and a lot of variability.

[Jake Anderson]

So what do the guidelines say? Well, the American Geriatric Society's Beers criteria flags antihypertensives as meds to use cautiously in adults over 65 and supports thoughtful deprescribing.

[Emily Eisenberg]

And the stop start criteria. Yes, that's a real acronym. Also help guide when to stop or start meds in older adults.

[Austin Cotter]

And the bottom line, Deprescribing antihypertensives can be safe in the right patient.

[Jake Anderson]

Just do it on purpose, not because someone read half a headline on Facebook. We have another main topic, Vertebral compression fractures. And it comes to us from Dr. Creech Organ and Dr. Organ from Uniformed Services University of Health Sciences in Bethesda.

[Austin Cotter]

What an important topic is. Over half a million vertebral compression fractures occur annually in the US Alone. And these fractures are both the most common complication of osteoporosis and diagnostic of osteoporosis.

[Emily Eisenberg]

The risk factors for vertebral compression fractures are the same as those for osteoporosis. Counterintuitively, obesity is protective against these fractures, which is hypothesized to be due to increased bone density from increased weight. Jake, how do these fractures happen?

[Jake Anderson]

Well, they happen due to axial load on the spine exceeding the strength of the vertebral bone. And the fracture pattern is considered stable since only the anterior column compresses while the middle and posterior columns remain intact.

[Austin Cotter]

And in people with osteoporosis, these axial loads usually result from simple motions. Sneezing, coughing, turning in bed. Justin, how do patients present after one of these compression fractures?

[Emily Eisenberg]

Well, because the fractures flex the spine and open neural foramen with anterior column collapse. Neurologic symptoms are rare, and 2/3 of these fractures are asymptomatic and discovered incidentally. Acute symptoms generally resolve between three to 12 months, though long term sequelae can occur and include chronic back pain, muscle atrophy from decreased activity and others.

[Jake Anderson]

Okay, so now that we know how they present, let's discuss evaluating the patients once they do. Always start with visual inspection for thoracic kyphosis or loss of lumbar lordosis. Then palpate for tender spinous processes to help guide imaging. And don't forget that neurologic assessment. Provocative tests include the closed fist percussion test. You're basically beating up your patient, the supine sign test and back pain inducing test. They sound terrible.

[Austin Cotter]

Yeah. And as far as imaging, start with inter posterior and lateral plane films where vertebral height loss of 20% in the compressed area is diagnostic. But if X rays are negative and suspicion remains high, clinical consensus is to proceed to CT or mri.

[Emily Eisenberg]

Connecticut and MRI are also indicated to further characterize plain films in the setting of new symptomatic compression fractures. If a patient has a history of malignancy and compression fractures on plain film, contrast enhanced MRI is the next step, regardless of symptoms.

[Jake Anderson]

A secondary osteoporosis workup should also be undertaken before deciding on management, but initial management should be conservative.

[Austin Cotter]

Initial conservative management includes pain control with NSAIDs, Tylenol and antiosteoporotic medications including bisphosphonates, intranasal calcitonin and teriparatide. Vitamin D and calcium supplementation should be continued with these treatments. Opiates and muscle relaxants are not recommended due to minimal benefit.

[Emily Eisenberg]

Additionally, physical rehabilitation should be started two weeks after fracture and split into multiple sessions. Conservative management with more mixed evidence include supportive bracing, nerve root blocks and facet joint injections. Still, what if none of this helps my patient?

[Jake Anderson]

If response is inadequate or persists for four to 10 weeks, then vertebral augmentation procedures can be considered. Outcomes between vertebroplasty and balloon kyphoplasty are pretty similar. But now onto the best treatment.

[Austin Cotter]

Prevention Prevention of vertebral compression fractures centers on prevention of osteoporosis, bone density screening, advice to quit tobacco and reduce alcohol intake, and supplementation of vitamin D and calcium in high risk individuals are all measures to identify and prevent osteoporosis and ultimately prevent vertebral compression fractures.

[Jake Anderson]

We're going to wrap this episode up with an FPIN clinical inquiry. Sublingual Buprenorphine for opioid Use Disorder treatment And it comes to us from the physician and pharmacist team of doctors Jackson, Fowl, Kim and Chang.

[Emily Eisenberg]

The clinical question here is what is the optimal dose of sublingual buprenorphine for maintenance treatment of opioid use disorder.

[Jake Anderson]

Yeah, I've definitely had this question before. Sometimes people are doing well on a certain dose of buprenorphine. And because it's such a safe medication, I've wondered if there's value in aiming for a specific dose or just following cravings and success in remission.

[Austin Cotter]

So the short answer here is that higher doses do seem to improve retention and treatment and are associated with both lower overdose related mortality and all cause mortality.

[Emily Eisenberg]

Diving a little bit further maintenance dosages of buprenorphine 24-40mg per day are associated with higher retention in treatment compared with those on 16mg. We've got numbers needed to treat in the 18 to 31 range. This was based on a 2025 US retrospective cohort study of prescription claims for buprenorphine naloxone.

[Austin Cotter]

The FPEN team also concluded, based on international trials, that use of higher dosages, which was 8 milligrams per day in this study, results in higher rates of treatment retention at 12 months than lower dosages which was defined as 3 milligrams per day and 1 milligram per day. This was based on a 2022 systematic review that included nine randomized controlled trials.

[Emily Eisenberg]

With over 2,100 patients and maybe most impressively, based on a large 2024 retrospective cohort study with over 49,000 patients, dosages of buprenorphine greater than 16 milligrams per day are associated with lower overdose related mortality NNT of one hundred and sixty seven and all cause mortality and our NNT there is 334.

[Austin Cotter]

A different large 2024 retrospective cohort study with over 35,000 patients found that dosages of 16 milligrams or greater and 24 milligrams or greater per day are associated with longer times to emergency department and hospital admission when compared with lower dosages.

[Emily Eisenberg]

Notably, the American Society of Addiction Medicine last issued guidelines on buprenorphine treatment for opioid use disorder in 2023. Prior to these large studies, they recommended buprenorphine dosages between 16 and 32 milligrams per day for optimum treatment retention and reduced extraneous opioid use. Send us your thoughts by emailing [e-mail] follow on Instagram @afpjournal. Please subscribe and rate us wherever you.

[Austin Cotter]

Get your podcasts Escuchenos en Espanol A Revista Medica a fap.

[Podcast Host/Producer]

Our podcast team is Jake Anderson, Puneet Baro, Steve Brown, Justin Chetiak, Sarah Coles.

[Austin Cotter]

Austin Cotter, Rachel Dunn, Emily Eisenberg, Elena.

[Emily Eisenberg]

Kelly, Chisam Okuabu, and Kari Staus.

[Podcast Host/Producer]

Our sound and technical guru is Tyler Coles. Our theme song is written and recorded by family physicians Bill Dabbs, Ryan Evans and Justin Jenkins.

[Austin Cotter]

This podcast is brought to you by the residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine Residency Programs.

[Emily Eisenberg]

We'll talk to you soon for the next edition of the American Family Physician Podcast.