Who should be tested for influenza?

The worst of flu season is November through February (at least in Boston) although it can be shorter or longer; flu should be considered in anyone presenting with a fever and cough or other viral symptoms during this time of year.

 

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image copyright: Working Nurse

Flu is a clinical diagnosis (see below) which means patients do NOT need a positive test result to get treated! If you think someone meets criteria for treatment, you can empirically give them antiviral medication. Plus, getting tested for flu is no fun: it’s a nasal swab, which has to go all the way back into the throat. However, as described below, certain kinds of patients should be tested.

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What are the basics of starting hormone replacement therapy?

Hormone replacement therapy (HRT) has gotten a bad rap since the Women’s Health Initiative showed that there was a slight increase in the number of older women getting breast cancer and heart disease. However, fifteen years later, the consensus is that for women under the age of 60 who are experiencing menopausal symptoms, hormone therapy may relieve symptoms without a significant increase in risk of heart disease and cancer. It should be noted that no one thinks prescribing HRT for chronic conditions like osteoporosis is beneficial.

What women might benefit from HRT? 
Menopausal symptoms include hot flashes, joint aches/pains, and vaginal atrophy/dyspareunia. The evidence supports using HRT in women <60 years of age. The risk of adverse effects increases with age.

NB: alternative treatments for hot flashes include bedtime gabapentin and a variety of SSRI/SNRIs. Paroxetine and citalopram can be considered (paroxetine is the only SSRI/SNRI FDA approved for treatment of hot flashes, but should not be used in women taking tamoxifen due to cytochrome p450 metabolism). Bazedoxifene/conjugated estrogen is a SERM combination therapy with estrogen that has been shown to be effective but also carries increased risk of VTE. Black cohosh is NOT supported. For women with milder symptoms, simply adjusting the thermostat or changing clothes may be acceptable, or cognitive-behavioral therapy.

NB: women who only have vaginal atrophy and dyspareunia can use estrogen cream instead of taking systemic therapy like pills or patches.

What are the contraindications to prescribing HRT? 

Absolute:

  • history of breast cancer
  • unexplained vaginal bleeding
  • high-risk endometrial cancer
  • Cardiovascular disease risk (CVD risk) >10% by JACC calculator or known CAD
  • previous venous thromboembolic event
  • previous stroke or TIA
  • active liver disease, i.e. cirrhosis

Relative:

  • hypertriglyceridemia
  • active gallbladder disease
  • hypercoagulable conditions like FVL, without known history of clot
  • migraine with aura is not a contraindication, but you might consider transdermal estrogen instead of oral (same for women with obesity)

What doses of estrogen should I prescribe? 

NB: estrogens come in creams, rings, vaginal formulations, patches, and pills. When thinking about dosing, remember to check for medication interactions as estrogen is metabolized by the liver. Women taking estrogen should also be counseled to avoid or limit alcohol intake for this reason.

  • Transdermal estrogen (the patch) can be started at 0.025 mg/day
  • Low-dose estrogen (pill) can be started at 0.5 mg/day

Check in after 1 month and titrate up for symptoms

Why the progestin, too? 

All women with a uterus should also receive progestin to prevent the increased risk of endometrial cancer from endometrial hyperplasia. (Women who have undergone hysterectomy do not need to take a progestin.) Oral micronized progesterone, which sometimes is called a “minipill.” Progesterone may cause nausea, bloating, and breakthrough bleeding that women can’t tolerate–in these cases, try continuous progesterone therapy, or consider an IUD or switching to a SERM/conjugated estrogen.

 

Managing testosterone (and its deficiency)

 

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This came up when I searched for “low testosterone”…I don’t think that’s the issue here. 

Very few men are brave enough to ask me, a woman, about “man troubles,” but when they do, I want to give them good counsel.* So, this post is really more like “here’s what I read on the Internet, hopefully it’s a helpful summary”:

Testosterone deficiency. Andropause. Male menopause. Low T. These are the terms your patient may have read about, and they want to know if you think they have it, and furthermore, if you think they need testosterone replacement therapy.

Is testosterone deficiency a real thing?

Short answer: yes, but you have to be strict in how you diagnose it. This is bolded in Up To Date, and whenever something is bolded in Up To Date, it’s important. This Science-Based Medicine article makes a convincing argument that testosterone deficiency has been oversold by the pharmaceutical industry in order to peddle patches, injections, etc. for profit.

What is the range of normal for testosterone in males?

300-1000 ng/dL.

How is testosterone deficiency diagnosed? 

Testosterone deficiency cannot be diagnosed in a single visit. Let me repeat that: it will take at least 2-3 visits/lab draws to make a diagnosis. That’s because testosterone levels fluctuate, and that is a normal thing!

Diagnosis requires repeatedly low morning-level testosterone levels PLUS factors like low libido, loss of morning erections, gynecomastia, loss of body hair, loss of bone density, or small testes.

Vague symptoms, like fatigue, depression, anemia, and loss of muscle strength are NOT enough on their own and should receive a broader workup.

What about in older men? I heard it’s different. 

Kind of? There is no one clear answer. It seems reasonable to treat older men for truly low testosterone levels, like <200 ng/dL who are having symptoms. Data shows that it does improve mood, energy, and sexual function. But there are no big studies of long-term side effects, so if one day it’s found that testosterone secretly causes cancer or dementia, you’ll be glad you were conservative.

Who can NOT receive testosterone?

Patient with severe prostatic hypertrophy, PSA >4.0, history of prostate cancer, erythryocytosis, uncontrolled heart failure. Some people say sleep apnea–this is not totally clear, but may be more of a co-variate. Obesity can lower testosterone levels, and is also associated with sleep apnea.

Before starting anyone on testosterone, make sure to do a prostate exam and PSA level. If the PSA is markedly elevated, you might need to make sure he doesn’t have prostate cancer first…

What are the different kinds of testosterone replacement? 

  • Transdermal: most people consider this the easiest method of administration, but it can be more expensive
  • Injections: can be given every 1-3 weeks depending, but the farther apart the injections are the more labile someone’s symptoms might be
  • Pills are an option, but have been linked with higher rates of hepatic disease
  • Sublingual formulation
  • Nasal gel
  • Subcutaneous implantable pellets (seriously, when there is money to be made, the possibilities are infinite)

What are the side effects of testosterone replacement?

  • Acne: the patch in particular can cause a nasty localized rash, although I think this is more like a contact dermatitis
  • Headaches
  • Hepatitis
  • Polycythemia: rare, but shows up on board questions
  • Fluid retention
  • Hypercholesterolemia
  • Insulin resistance:
  • Infertility: this is not immediately apparent to people, and you should ask your patient if they are planning on conceiving prior to prescribing testosterone. Interestingly, testosterone has been explored as a contraceptive agent.

Labs should be monitored regularly: CBC, LFTs, lipid panel. Testosterone levels can be checked every few months for efficacy, too.

How is testosterone for transgender patients prescribed? Are there any caveats to be aware of? 

Technically, using testosterone for gender transition is off-label. Shameless social justice plug: some friends and I made a document about caring for vulnerable populations, including transgender patients, and you can find more information there.

Testosterone is prescribed in any of the forms described above at similar doses. Many providers will cite “other endocrine dysfunction” instead of “gender identity disorder” or “gender dysphoria” as this is less stigmatizing.

The patient expects to experience deepening of the voice, male pattern hair growth, clitoromegaly, and atrophic vaginitis, among other things. However, breast tissue atrophies less than most people expect. Typical side effects also apply.

* This information is relevant to adults, not to children or adolescents.

What’s the difference between D2 and D3 for supplementation? And when should you supplement?

I have to look this up myself every time:
D2=ergocalciferol
D3=cholecalciferol

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precisionnutrition.com

One study, albeit small, looked at the effects of vitamin D3 versus D2 supplementation and found that D2 potency is less than 30% of that of D3 and that it has a markedly shorter duration of action. Because the 1,25 form is metabolized in the kidney, D2 is not recommended for patients with CKD or ESRD (D3 should be used). One paper even argues that vitamin D2 should not be sold as a supplement anymore.

Random fact: vitamin D supplementation is a USPSTF grade B recommendation for elderly adults for fall prevention.

Prescribing vitamin D for vitamin D-deficient patients is surprisingly controversial. There are gray areas like what truly counts as “low vitamin D,” racial differences in vitamin D levels (most discussions of vitamin D supplementation are based on evidence in Caucasians), and who should be screened in the first place.

However, here are the quick and dirty guidelines from UpToDate:

Generally, vitamin D deficiency is a serum 25 (OH)D level <20 ng/ml. A couple of specialty societies suggest that a level <30 ng/ml is cause for supplementation in pts >age 65. However people are usually not at risk for osteomalacia unless <10 ng/ml.

Normal adults do NOT need to be screened, but the elderly, those with poor sunlight exposure and malabsorptive disease, should be.

D3 (cholecalciferol) is thought to be more efficacious than D2 (ergocalciferol). Although you will often see someone prescribed 50,000 U weekly followed by 600-800 U daily, there is no evidence behind the 50,000–so you might as well just start them on 600-800 U daily. Vitamin D levels should be monitored every 3-4 months until the target level is met. If someone has malabsorptive disease or isn’t responding to initial treatment, they may require increase of their dose.

What’s the best test to diagnose chlamydia?

Highlights from MMWR:

  • NAAT testing is the gold standard. Who even gets cultures anymore? And serologies are useless.
  • Vaginal swabs are preferred for women; cervical swabs have equal sensitivity. Urine tests may be up to 10% less sensitive but are also specific.
  • For heterosexual men, there are no specific recommendations, but you might as well get it as part of STI screening. First-catch urine samples are superior to clean-catch.
  • For certain populations, such as those who have anal intercourse, a rectal swab is appropriate. An oropharyngeal swab may be appropriate, too, especially in prepubescent girls or children who have been sexually assaulted; also in those with suspected treatment-resistant gonorrhea because of the rates of co-infection.

What regimen can I give a patient going through opiate withdrawal? 

This is the typical cocktail our psychiatry consultants recommend:

  • Robaxin 500-700 mg q6h prn muscle cramps
  • Bentyl 50 mg prn abdominal pain
  • Clonidine 0.1 mg prn anxiety, hold for systolic blood pressure <90
  • Hydroxyzine 50 mg q6h prn anxiety or insomnia
  • Kaopectate prn diarrhea

Always make sure to check a tox screen to make sure they’re not going through concurrent alcohol or benzo withdrawal!