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

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.

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)

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)

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)

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)

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)

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)

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)

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

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) |

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.