Primary Care & Urgent Care Reference

URI / Acute Bronchitis

Dx: Viral >90%. Cough lasts 2–3 weeks (up to 6). Sputum color means nothing. R/o: influenza, strep, bacterial sinusitis, allergic rhinitis, pertussis, pneumonia.

Rx — no antibiotics, regardless of cough duration

• Acetaminophen 1000 mg q6h (max 4 g/day; cap at 3 g if elderly, hepatic disease, or regular alcohol) or ibuprofen 400–600 mg q6h
• Dextromethorphan 20 mg q4h; honey (≥1 yr); guaifenesin
• Intranasal ipratropium 0.06% for rhinorrhea; saline irrigation
• Albuterol only if wheezing. No routine oral steroids.
• Script the counseling: “3 weeks of cough is normal; green mucus is not infection.” Offer a written return-precautions sheet or a delayed/back-up prescription — both cut re-visits and satisfy the patient who came for an antibiotic.

CXR if: T >38 °C, HR >100, RR >24, SpO₂ <95%, focal findings, frail/elderly, or deteriorating.

Acute Bacterial Rhinosinusitis

Treat only if ONE of three:

• Symptoms ≥10 days without improvement
• Severe onset: T ≥39 °C + purulent discharge or facial pain, ≥3–4 consecutive days
• Double-sickening: worsening after initial improvement (~day 5–6)

Rx

• Amox-clav 875/125 mg PO BID × 5–7 d (first line)
• High-dose amox-clav 2000/125 mg BID × 7–10 d if: >65, recent hospitalization, antibiotic in past month, immunocompromised, daycare exposure, severe illness
• PCN allergy: doxycycline 100 mg BID × 5–7 d
• Adjunct: intranasal steroid, saline irrigation, decongestant ≤3 d

Do NOT use azithromycin or TMP-SMX — pneumococcal resistance 30–40%. Amoxicillin alone no longer preferred (H. flu beta-lactamase).

Red flags → CT + ENT/ED: periorbital edema, proptosis, ophthalmoplegia, vision change, severe headache, AMS, meningismus, forehead swelling (Pott’s puffy tumor).

Group A Strep Pharyngitis

Centor/McIsaac (1 pt each): T >38 °C · tonsillar exudate/swelling · tender anterior cervical nodes · absence of cough · age 3–14 (+1), 15–44 (0), ≥45 (−1)

• 0–1 → no test, no antibiotics
• ≥2 → rapid antigen test. Children with negative RADT get back-up culture; adults do not.
• Never treat empirically on score alone. Don’t test with cough, coryza, hoarseness, oral ulcers, or conjunctivitis.

Rx

• Penicillin VK 500 mg PO BID × 10 d — or amoxicillin 500 mg BID (or 1000 mg daily) × 10 d
• Peds: amoxicillin 50 mg/kg daily (max 1000 mg) × 10 d
• Non-anaphylactic PCN allergy: cephalexin 500 mg BID × 10 d
• Anaphylactic: clindamycin 300 mg TID × 10 d, or azithromycin 500 mg → 250 mg × 4 d (rising GAS macrolide resistance)
• GAS has never been reported resistant to penicillin.

Red flags: trismus, drooling, hot-potato voice, unilateral tonsillar bulge/uvular deviation (peritonsillar abscess), stridor (epiglottitis), unilateral neck pain + sepsis (Lemierre).

Otitis Media & Otitis Externa

AOM — peds. Dx requires effusion + moderate-severe TM bulging, or new otorrhea, or mild bulging + pain <48 h. Observe 48–72 h if ≥2 yr, unilateral, no otorrhea, non-severe, reliable follow-up. Treat now if <6 mo, 6–23 mo bilateral, otorrhea, severe, or unreliable follow-up.

• Amoxicillin 80–90 mg/kg/day divided BID
• Amox-clav 90/6.4 mg/kg/day if amoxicillin in past 30 d, purulent conjunctivitis, or recurrent AOM
• Duration: <2 yr or severe → 10 d; 2–5 yr → 7 d; ≥6 yr → 5–7 d
• Allergy: cefdinir 14 mg/kg/day; ceftriaxone 50 mg/kg IM × 1–3 d if vomiting/failure

AOM — adult. Amoxicillin 875 mg BID or amox-clav 875/125 BID × 5–7 d; doxycycline if allergic. Unilateral serous effusion in an adult with no infection → think nasopharyngeal mass, refer.

Otitis externa. Tragal traction tenderness. Topical only — oral antibiotics are not indicated.

• Ofloxacin 0.3% otic, 10 gtt daily × 7 d — the only otic FDA-labeled for a perforated TM, so it’s the choice when integrity is uncertain
• Ciprofloxacin 0.3%/dexamethasone 4 gtt BID × 7 d — intact TM, or tubes
• Avoid neomycin-containing drops if TM perforated or tubes present
• Wick if canal too edematous
• Necrotizing OE: elderly/diabetic, granulation at bony-cartilaginous junction, severe night pain, cranial neuropathy → emergent ENT

Mastoiditis red flags: postauricular swelling with protruding auricle, facial palsy, vertigo, meningismus.

Eustachian Tube Dysfunction

Secondary to rhinosinusitis vs allergy.

• Pseudoephedrine 24 h 240 mg 1 tab daily
• Intranasal steroid (fluticasone 2 sprays each nostril daily) — the workhorse
• Methylprednisolone dose pack for refractory
• Antihistamine if allergic component; consider Otovent device
• Autoinsufflation, chewing gum, Valsalva
• Give it up to 3 months, then image / refer — persistent unilateral ETD in an adult raises suspicion of a mass lesion.

Allergic Rhinitis

• Intranasal steroid is first line — fluticasone propionate 50 mcg, 2 sprays each nostril daily (OTC, ~$11)
• Add oral 2nd-gen antihistamine: cetirizine 10 mg or loratadine 10 mg daily (buy OTC — never write it)
• Intranasal azelastine for breakthrough; montelukast only if asthma overlap (neuropsych boxed warning)
• Saline irrigation; allergen avoidance; consider immunotherapy referral

Influenza

Treat empirically — do not wait for the test. Greatest benefit <48 h, but treat later if high-risk, severe, or progressive.

Who to treat: age ≥65 or <2, pregnancy/≤2 wk postpartum, chronic lung/cardiac/renal/hepatic/heme/metabolic/neuro disease, immunosuppression, BMI ≥40, LTC residents, American Indian/Alaska Native, <19 on chronic aspirin. Consider in healthy patients within 48 h.

• Oseltamivir 75 mg PO BID × 5 d — reduce if CrCl <60 (30–60: 30 mg BID; 10–30: 30 mg daily)
• Baloxavir: single dose, 40 mg (40–<80 kg) or 80 mg (≥80 kg), age ≥5. Avoid in pregnancy, breastfeeding, severe immunosuppression, hospitalized/progressive illness.
• Zanamivir 10 mg inhaled BID × 5 d — avoid in asthma/COPD
• Prophylaxis: oseltamivir 75 mg daily × 7 d

COVID-19 (outpatient)

Nirmatrelvir-ritonavir (Paxlovid) 300/100 mg PO BID × 5 d — start within 5 days of onset

• eGFR 30–<60: 150/100 BID × 5 d
• eGFR <30 (incl. HD): 300/100 on day 1, then 150/100 daily days 2–5
• High risk = age ≥60, diabetes, BMI >25, chronic lung/cardiac/kidney/liver disease, HTN, smoking, immunosuppression, active cancer, sickle cell
• Screen the med list every time. Contraindicated with amiodarone, flecainide, propafenone, ranolazine, colchicine, eplerenone, finerenone, lovastatin, simvastatin, alfuzosin, silodosin, oral midazolam, triazolam, pimozide, lurasidone, ergots, carbamazepine, phenytoin, phenobarbital, rifampin, apalutamide, St. John’s wort, ubrogepant, eletriptan.
• Alternatives: remdesivir 200 mg IV → 100 mg × 2 d (within 7 d); molnupiravir 800 mg BID × 5 d (last line, not in pregnancy)

Pertussis

Paroxysmal cough, whoop, post-tussive emesis, cough >2 wk. Azithromycin 500 mg day 1, then 250 mg days 2–5. Treat household contacts. Report to public health.

Community-Acquired Pneumonia (outpatient)

CURB-65 (1 pt each): Confusion · BUN >19 · RR ≥30 · SBP <90 or DBP ≤60 · age ≥65 → 0–1 outpatient, 2 consider admit, ≥3 admit.

Healthy, no comorbidities:

• Amoxicillin 1 g PO TID (preferred) or doxycycline 100 mg BID
• ⚠️ Azithromycin monotherapy is inappropriate in most of the US — pneumococcal macrolide resistance ≈40% nationally (threshold for monotherapy is <25%)

With comorbidities (heart/lung/liver/renal disease, DM, alcohol use, malignancy, asplenia):

• Amox-clav 875/125 BID (or cefpodoxime 200 BID) PLUS doxycycline 100 BID or a macrolide
• Monotherapy alternative: levofloxacin 750 mg daily or moxifloxacin 400 mg daily — reserve

Duration: ≥5 days and until clinically stable (afebrile, HR ≤100, RR ≤24, SBP ≥90, SpO₂ ≥90, normal mentation and PO intake).

Uncomplicated Cystitis (women)

Dysuria + frequency + urgency without vaginal discharge → treat empirically, no culture needed. Culture if recurrent, treatment failure, pregnant, atypical, or complicated.

• Never amoxicillin or ampicillin empirically. Avoid nitrofurantoin if CrCl <30 or pyelo suspected.
• Fluoroquinolones: FDA says reserve for patients with no alternative in uncomplicated UTI.
• Phenazopyridine 200 mg TID × 2 d for symptom relief.

Pyelonephritis (outpatient): cipro 500 mg BID × 7 d (± ceftriaxone 1 g IM × 1 if local FQ resistance ≥10%), or levofloxacin 750 mg daily × 5 d. Admit for instability, vomiting, pregnancy, obstruction, immunocompromise, or male sex.

Gastroenteritis & Traveler’s Diarrhea

Oral rehydration is the treatment. No empiric antibiotics.

Stool testing if: fever, bloody/mucoid stool, severe pain, dysentery, immunocompromise, sepsis, >7 days, recent antibiotics or travel. ⚠️ Withhold antibiotics and anti-motility agents if STEC/O157 suspected (bloody diarrhea, little fever, esp. children) — raises HUS risk.

• Loperamide 4 mg → 2 mg after each loose stool: fine for watery, afebrile, non-bloody
• Ondansetron 4–8 mg ODT for vomiting
• Traveler’s diarrhea: mild → loperamide/bismuth only. Moderate-severe or dysentery → azithromycin 1000 mg × 1 (preferred; only agent reliable in South/SE Asia). Rifaximin 200 mg TID × 3 d for watery, non-febrile only.

C. difficile (outpatient): fidaxomicin 200 mg BID × 10 d (preferred) or vancomycin 125 mg PO QID × 10 d. Metronidazole only if neither available. Stop the inciting antibiotic. No test-of-cure, never test formed stool.

GERD / Dyspepsia

• Omeprazole 20 mg or pantoprazole 40 mg PO daily × 8 wk, 30–60 min before breakfast (~$6/mo)
• Lifestyle: weight loss, elevate head of bed, no late meals, trim alcohol/caffeine/NSAIDs
• Test-and-treat H. pylori if <60 with dyspepsia: quadruple therapy (PPI BID + bismuth 300 mg QID + metronidazole 500 mg QID + tetracycline 500 mg QID × 14 d) — clarithromycin regimens are failing
• Alarm features → EGD: dysphagia, odynophagia, weight loss, GI bleed, anemia, vomiting, mass, age >60 with new dyspepsia

Skin & Soft Tissue Infection

The fork is purulent vs nonpurulent.

Nonpurulent cellulitis / erysipelas — strep; MRSA coverage not needed

• Cephalexin 500 mg PO QID × 5 d (1 g q8h if obese or large limb)
• PCN allergy: clindamycin 300–450 mg TID–QID
• TMP-SMX and doxycycline are poor choices here (unreliable strep activity)
• Elevate the limb; treat tinea pedis and edema — the two big recurrence drivers
• Bilateral lower-leg “cellulitis” is almost always stasis dermatitis. Do not treat it with antibiotics.

Purulent — abscess/furuncle/carbuncle

• I&D is the treatment. Add MRSA-active antibiotics if >2 cm, multiple lesions, surrounding cellulitis, SIRS, immunosuppressed, extremes of age, face/hand/genital, or failed I&D
• TMP-SMX 1–2 DS BID × 5–7 d or doxycycline 100 mg BID × 5–7 d
• ⚠️ TMP-SMX: hyperkalemia with ACEi/ARB/spironolactone, and it potentiates warfarin — check the med list before you write it
• Adding an antibiotic after I&D cuts failure ~5% and recurrence ~8% — cephalosporins add nothing (miss MRSA)

Necrotizing infection — surgical emergency: pain out of proportion, hourly progression, crepitus, bullae, skin anesthesia, dusky skin, hypotension. Also urgent: orbital, flexor tenosynovitis (Kanavel), Fournier’s, bites, water exposure.

Impetigo: limited → mupirocin 2% TID × 5 d. Extensive/bullous → cephalexin or dicloxacillin 250–500 mg QID × 7 d.

Herpes Zoster & HSV

• Zoster: valacyclovir 1 g PO TID × 7 d, start within 72 h (or any time if new lesions still appearing). Renal-adjust — this is a common and neurotoxic error in the elderly: CrCl 30–49 → 1 g q12h · 10–29 → 1 g q24h · <10 → 500 mg q24h. Gabapentin or nortriptyline for pain. Ophthalmic branch (Hutchinson’s sign) → same-day ophtho.
• HSV genital, first episode: valacyclovir 1 g BID × 10 d. Recurrence: 500 mg BID × 3 d. Suppression: 500–1000 mg daily.
• Cold sore: valacyclovir 2 g BID × 1 day.

Fungal & Yeast

• Tinea corporis/cruris/pedis: terbinafine 1% or ketoconazole 2% cream BID × 2–4 wk (4–6 wk for pedis)
• Onychomycosis: confirm first (KOH/PAS), then terbinafine 250 mg daily × 6 wk fingernails / 12 wk toenails; baseline LFTs
• Tinea capitis: oral required — griseofulvin or terbinafine; never topical alone
• Vaginal candidiasis: fluconazole 150 mg × 1 (repeat in 72 h if severe)
• Tinea versicolor: ketoconazole 2% shampoo, 10 min daily × 1–2 wk

Urticaria

Explore triggers: new meds, foods, recent infection (most acute urticaria is post-viral and never gets an answer).

• Cetirizine 10 mg daily, up-dose to 20–40 mg/day as needed — 2nd-gen antihistamines are first line, and guidelines support 4× dosing
• Add H2 blocker (famotidine 20 mg BID) and hydroxyzine 25 mg qhs for night itch
• Topical steroid for localized lesions
• Prednisone 40 mg daily × 5 d for severe/refractory only — no taper needed

6 weeks = chronic → check CBC, TSH, CMP; refer to allergy/derm

• Angioedema of lips/tongue, stridor, hypotension → epinephrine 0.3 mg IM, 911. Consider ACE-inhibitor–induced angioedema (may appear years into therapy — stop the drug permanently).

Conjunctivitis

• Bacterial: thick purulent discharge, lids matted on waking, discharge returns within minutes of wiping
• Viral (most common): watery, preauricular node, recent URI, gritty
• Allergic: bilateral, itching predominant, stringy

Most bacterial conjunctivitis is self-limited (55% resolve on placebo by day 4–9 vs 68% with antibiotics). Supportive care ± delayed prescription is reasonable.

• Treating: erythromycin 0.5% ointment QID × 5–7 d, or polymyxin B/trimethoprim 1–2 gtt q3–6h
• Contact lens wearer must have Pseudomonas coverage → moxifloxacin 0.5% TID–QID; stop lenses until 24 h after resolution
• Never topical steroids; never aminoglycosides

Same-day ophtho: vision loss, real pain, photophobia, ciliary flush, corneal infiltrate, irregular pupil, hyperacute copious purulent discharge (gonococcal — needs IM ceftriaxone), herpetic dendrite, contact lens wearer with pain, neonate.

Dental Pain / Abscess

Antibiotics are NOT indicated for pulpitis, necrosis, or a localized apical abscess in an immunocompetent adult — the treatment is definitive dental care.

• Ibuprofen 600 mg + acetaminophen 1000 mg q6h outperforms opioids
• Antibiotics only for systemic involvement (fever, malaise, adenopathy, trismus, spreading swelling) or when dental care isn’t available: amoxicillin 500 mg TID × 3–7 d; cephalexin 500 QID; azithromycin or clindamycin if severe allergy
• Ludwig angina: floor-of-mouth swelling, elevated tongue, trismus, drooling, dysphagia, stridor → ED, airway, CT, surgical drainage

Acute Low Back Pain

Red flags: age >50 new onset, cancer history, unexplained weight loss, fever, IVDU, trauma, night pain, saddle anesthesia, urinary retention/incontinence, progressive weakness, steroid use, recent infection. Cauda equina → emergent MRI.

No imaging in the first 6 weeks without a red flag.

• Stay active — bed rest worsens outcomes. Superficial heat, massage, spinal manipulation, acupuncture.
• NSAID first line: naproxen 500 mg BID or meloxicam 15 mg daily. Acetaminophen doesn’t work for back pain.
• Muscle relaxant short course: cyclobenzaprine 5–10 mg qhs or tizanidine 4 mg TID PRN (sedating — counsel)
• Systemic steroids are ineffective for nonradicular pain
• Chronic: exercise, PT, CBT, yoga/tai chi → NSAIDs → duloxetine 60 mg daily → tramadol → opioids last

Osteoarthritis

• Topical NSAID is first line for knee and hand OA — preferred over oral if ≥75, or GI/renal/CV risk. Diclofenac 1% gel 4 g QID per knee (max 16 g/joint/day, 32 g/day total); 2 g QID per hand. ~$11 for 100 g.
• Oral: meloxicam 15 mg daily, naproxen 500 mg BID, celecoxib 200 mg daily (best CV/GI balance)
• Duloxetine 30 mg × 1 wk → 60 mg daily — strongly recommended for knee OA
• Exercise, weight loss, PT — the highest-yield interventions
• Intra-articular steroid (see injections). Against: glucosamine, hyaluronic acid, PRP, stem cells

Gout

Acute flare — start within 24 h, any one:

• Indomethacin 50 mg TID or naproxen 500 mg BID × 5–7 d
• Colchicine 1.2 mg → 0.6 mg one hour later, then 0.6 mg daily/BID. ⚠️ Reduce or avoid with CrCl <30, hepatic impairment, or any strong CYP3A4/P-gp inhibitor (clarithromycin, azoles, diltiazem, verapamil, ritonavir) — that combination is fatal.
• Prednisone 40 mg daily × 5 d — preferred in CKD
• Intra-articular steroid for a single joint

Never interrupt urate-lowering therapy a patient is already on. ACR 2020 also permits starting ULT during a flare, under anti-inflammatory cover — waiting for resolution is no longer required.

Urate-lowering (ULT) if ≥2 flares/yr, tophi, erosions, or CKD ≥3: allopurinol 100 mg daily (50 mg if CKD), titrate q2–5 wk to uric acid <6.0; typical 300–600 mg, max 800. Prophylax with colchicine 0.6 mg daily × 3–6 months while titrating. Consider HLA-B*5801 in Han Chinese, Thai, Korean patients.

Neuropathic Pain

First line: gabapentinoid, SNRI, or TCA.

• Gabapentin 300 mg day 1 → 600 → 900, titrate to 1800 mg/day divided TID; renal-adjust (CrCl 30–59: 400–1400 mg/day). Not scheduled in California.
• Duloxetine 30 mg × 1 wk → 60 mg daily (no benefit at 120). Avoid if GFR <30 or any hepatic impairment.
• Pregabalin (C-V) 75 mg BID → 150 mg BID; max 300 mg/day for DPN
• Nortriptyline 10–25 mg qhs → 75 mg (better tolerated than amitriptyline; anticholinergic caution ≥65)
• Topical: lidocaine 5% patch 12 h on/12 h off; capsaicin 8% patch
• Opioids are recommended against before these fail.

Migraine

Acute — treat early, while pain is mild

• Sumatriptan 50–100 mg PO (max 200/day) + naproxen 500 mg — strongest combination evidence; ACP 2025 strongly recommends adding a triptan to an NSAID
• Rizatriptan 10 mg ODT (max 30/day) — highest 2 h pain-free rate
• Metoclopramide 10 mg or prochlorperazine 10 mg for nausea/rescue
• Triptan contraindicated (CAD, stroke, uncontrolled HTN) → gepant: ubrogepant 50–100 mg (max 200/24 h) or rimegepant 75 mg ODT. No vasoconstriction.
• Medication overuse (ICHD-3): simple analgesics/NSAIDs ≥15 days/mo; triptans, combination analgesics, ergots, or opioids ≥10 days/mo. Practical counseling target: keep triptans under 10 days and NSAIDs under 15 days a month.

Prevention — indicated at ≥4 migraine days/mo or significant disability (MIDAS ≥11, HIT-6 >50)

• CGRP agents are now first line — AHS says no step therapy required. Erenumab 70–140 mg SC monthly; galcanezumab 240 mg load → 120 mg monthly; fremanezumab 225 mg monthly; atogepant 10–60 mg PO daily.
• Cheap generics still reasonable: propranolol 40–160 mg/day, topiramate 25 → 50–100 mg/day, amitriptyline 10–50 mg qhs, ~$6/mo each
• Chronic migraine (≥15 headache days/mo): onabotulinumtoxinA 155 U q12wk

Sprains, Strains & Imaging Rules

Ottawa Ankle Rules — x-ray only with malleolar/midfoot pain AND any of:

• Bone tenderness at posterior edge/tip of lateral malleolus (distal 6 cm)
• Bone tenderness at posterior edge/tip of medial malleolus (distal 6 cm)
• Bone tenderness at base of 5th metatarsal or navicular (foot series)
• Unable to bear weight 4 steps both at injury and in the room (limping counts as bearing weight)

Ottawa Knee Rule — x-ray if any one: age ≥55 · isolated patellar tenderness · fibular head tenderness · can’t flex to 90° · can’t bear weight 4 steps.

Canadian C-Spine Rule (alert, GCS 15, stable trauma)

• Any high-risk factor → image: age ≥65, extremity paresthesias, dangerous mechanism (fall ≥3 ft/5 stairs, axial load, MVC >100 km/h or rollover or ejection, motorized recreational vehicle, bicycle collision)
• Any low-risk factor allowing safe ROM testing? simple rear-end MVC · sitting in the office · ambulatory at any time · delayed neck pain · no midline tenderness. If none → image.
• Can actively rotate 45° left AND right? Pain during rotation is OK. Yes → no imaging.

Treatment: relative rest, early mobilization, NSAIDs, functional bracing. RICE with early weight-bearing beats immobilization.

Hypertension — 2025 AHA/ACC

Target: <130/80 for everyone, aim SBP <120 when tolerated. (The old “150/90 over age 60” target is gone.) Confirm with home BP monitoring.

When to start drugs

• Stage 2 (≥140/90): start now — and start two agents, preferably a single-pill combination
• Stage 1 + high risk (PREVENT 10-yr CVD ≥7.5%, or diabetes, CKD, or known CVD): start now
• Stage 1 + low risk: lifestyle 3–6 months, then treat if still ≥130/80

First line (any of four): thiazide-type diuretic · long-acting dihydropyridine CCB · ACEi · ARB. Never ACEi + ARB together. Beta-blockers are not first line without a compelling indication.

Chlorthalidone is longer-acting and more potent than HCTZ — the preferred thiazide.

Also: check UACR in every hypertensive patient (now recommended for all). ACEi/ARB is Class 1 in CKD with albuminuria. Screen all resistant HTN for primary aldosteronism regardless of potassium. Consider a GLP-1 RA if overweight/obese. Lifestyle: DASH, sodium <2300 mg (ideal 1500), ≤2 drinks/day men and ≤1 women, 75–150 min/wk activity, weight loss.

Type 2 Diabetes — ADA 2026

Targets: A1c <7% most adults (<6.5% if easily achieved, <8% if frail/limited life expectancy). Fasting/premeal 80–130, 2 h postprandial <180. CGM time-in-range >70%. A1c q3 mo if not at goal, q6 mo if stable.

Pharmacotherapy is now comorbidity-driven, not strictly metformin-first.

Doses

• Metformin 500 mg BID → 2000 mg/day (max 2550). Contraindicated eGFR <30; don’t initiate 30–45. Check B12.
• Dapagliflozin 10 mg daily ← generic since April 2026, ~$7/mo. Make this your default SGLT2i. (Empagliflozin has no generic — ~$250/mo cash.)
• Semaglutide SC 0.25 mg weekly × 4 → 0.5 → 1 → 2 mg. Oral (Rybelsus) 3 → 7 → 14 mg.
• Tirzepatide 2.5 mg weekly × 4 → 5 mg, ↑2.5 mg q4wk, max 15 mg
• Sulfonylurea (glipizide 5 mg daily, ~$6/mo) if cost is the binding constraint — cheap, but hypoglycemia and weight gain
• SGLT2i: hold for illness/surgery (euglycemic DKA), counsel on genital mycotic infection

Insulin — start regardless of other therapy if symptomatic catabolism, A1c >10%, or glucose ≥300

• Basal 0.1–0.2 units/kg/day (or ~10 units), titrate to fasting goal
• Prandial: add at the largest meal, 4 units or 10% of basal
• Prefer a GLP-1 RA over insulin when insulin deficiency isn’t established; if using insulin, combine with GLP-1 RA
• Reduce sulfonylurea/insulin when adding an agent

Annually: UACR + eGFR, dilated eye exam, comprehensive foot exam (visual check every visit), lipids, BMI, and — new in 2026 — screen for diabetes distress and anxiety.

Lipids — 2026 ACC/AHA

Numeric LDL goals are back, and PREVENT-ASCVD replaces the Pooled Cohort Equations (10-yr risk: low <3%, borderline 3–<5%, intermediate 5–<10%, high ≥10%). PREVENT scores run lower than PCE — don’t compare them.

High intensity (≥50% LDL reduction): atorvastatin 40–80 mg, rosuvastatin 20–40 mg Moderate (30–49%): atorvastatin 10–20 mg, rosuvastatin 5–10 mg, simvastatin 20–40 mg, pravastatin 40–80 mg

• All clinical ASCVD → high intensity
• LDL ≥190 → high-intensity statin + ezetimibe, goal <100
• Ages 40–75 with diabetes, CKD 3–4, or HIV → treat regardless of risk score
• Ezetimibe 10 mg is the first add-on whenever goal isn’t met (~20% further reduction, ~$6/mo). Then PCSK9 inhibitor / bempedoic acid / inclisiran.
• Lp(a) once in every adult’s lifetime. ApoB if TG >200, diabetes, or LDL already <70.
• Non-fasting panel is fine (fast only if TG ≥400). Recheck 4–12 wk after any change. Routine CK/LFTs not required.
• CAC to reclassify borderline/intermediate; CAC = 0 supports deferring a statin in the absence of diabetes, smoking, or FH.
• Fibrates, niacin, and omega-3 supplements are no longer recommended as add-ons for CV risk.

Asthma

SABA-only is no longer recommended at any step. Everyone gets ICS-containing therapy.

GINA Track 1 (preferred) — ICS-formoterol is both controller and reliever

Ceiling: 12 inhalations of ICS-formoterol/24 h — hitting it means seek care.

Track 2 (US-familiar, use if Track 1 isn’t feasible or the payer balks)

• Step 1: as-needed ICS-SABA (albuterol-budesonide) · Step 2: daily low-dose ICS + PRN SABA
• Step 3: low-dose ICS-LABA — budesonide-formoterol 80/4.5, 2 puffs BID (or 160/4.5, 1 puff BID) · Step 4: medium-dose — 160/4.5, 2 puffs BID · Step 5: refer

⚠️ US caveat: NAEPP 2020 (which payers follow) still lists SMART as preferred at steps 3–4 and hasn’t adopted as-needed-ICS-formoterol at step 1. Single-inhaler MART is off-label in the US for the reliever role.

Cash reality: albuterol HFA ~$12–28; any controller inhaler is $95–290/month. Budget for it up front — see Part 8.

Exacerbation: prednisone 40–50 mg daily × 5 d (no taper), albuterol 4–8 puffs with spacer q20 min × 3.

COPD

• Confirm with spirometry — post-bronchodilator FEV1/FVC <0.70
• Group B (symptomatic): LABA + LAMA combination
• Group E (≥2 exacerbations or 1 hospitalization): LABA + LAMA; add ICS if eosinophils ≥300
• Smoking cessation is the only intervention that changes mortality — varenicline 0.5 mg → 1 mg BID × 12 wk, or combination NRT
• Vaccines: influenza, COVID, PCV20/21, RSV, Tdap
• Pulmonary rehab for anyone with mMRC ≥2
• Exacerbation: prednisone 40 mg × 5 d + azithromycin 500 mg × 1 then 250 mg × 4 d (or doxycycline) if increased sputum purulence

Hypothyroidism

• Check TSH; if elevated, add free T4. Treat overt hypothyroidism (high TSH + low free T4).
• Subclinical (high TSH, normal free T4): treat if TSH >10; consider treating anywhere from the upper reference limit (~4.5) to 10 if symptomatic, TPO-antibody positive, or age <65
• Levothyroxine 1.6 mcg/kg/day for overt; 25–50 mcg daily to start if elderly, CAD, or subclinical
• Take fasting, 30–60 min before food, away from calcium/iron/PPI
• Recheck TSH in 6–8 weeks after any dose change, then annually

Depression & Anxiety

Screen with PHQ-9 (depression, grade B all adults) and GAD-7 (anxiety, grade B ages 19–64; USPSTF issued an I statement for ≥65).

• Sertraline 50 mg daily (25 mg if anxious/elderly) → 100–200 mg — good first choice for both
• Escitalopram 10 → 20 mg daily; bupropion XL 150 → 300 mg (no sexual side effects, no weight gain, avoid in seizure/eating disorder); duloxetine 60 mg if comorbid pain
• Allow 4–6 weeks at a therapeutic dose before calling it a failure
• Trazodone 50 mg qhs for insomnia; hydroxyzine 25 mg PRN for anxiety instead of a benzodiazepine
• Always ask about suicidal ideation with PHQ-9 item 9 positive. Same-day evaluation for plan or intent. 988 Suicide & Crisis Lifeline.
• All of these run $5.50–$6.50/month cash — cost should never be the barrier

Menopausal Hormone Therapy — Candidacy

The window of opportunity: age <60 OR within 10 years of menopause. This is now in the FDA label text, not just the guidelines. Outside the window, initiation needs individual justification — CVD, stroke, VTE, and dementia risk all rise.

Indications

• Moderate-to-severe vasomotor symptoms — the primary indication; ~75% improvement vs 20–60% for non-hormonal
• Genitourinary syndrome of menopause — use local vaginal therapy if GSM is the only complaint
• Osteoporosis prevention — estrogen is not approved to treat established osteoporosis. Bone loss after stopping is fast: 3–6% in year 1, back to never-user BMD within 2 years.
• POI / early menopause — see below

Absolute contraindications

• Unexplained abnormal genital bleeding
• Current or prior breast cancer; estrogen-dependent neoplasia
• Active or prior DVT/PE; known thrombophilia (protein C or S, antithrombin deficiency)
• Active or prior arterial thromboembolic disease (MI, stroke)
• Hepatic impairment or disease
• Prior anaphylaxis or angioedema to the product

Relative — use transdermal, or reconsider: uncontrolled HTN · hypertriglyceridemia · migraine with aura · gallbladder disease · obesity · diabetes · initiation after 65 with comorbidity · endometriosis (may flare).

FDA boxed warning status — get this right when patients ask. In Nov 2025 HHS/FDA requested removal; in Feb 2026 FDA approved changed labeling for only six products (Bijuva, Divigel, Cenestin, Enjuvia, Prometrium, Estring), removing CV disease, breast cancer, and probable dementia from the box. Estrogen-alone products keep an endometrial cancer boxed warning. Premarin, Vagifem, Imvexxy, Estrace cream and most patches still carry the full 2003-era warning. Do not tell a patient “the black box is gone” — say which warning, on which product. No society has changed its position statement; The Menopause Society 2022 remains current.

MHT — Systemic Regimens

Transdermal estradiol is first line. It bypasses first pass, so it does not raise hepatic procoagulant proteins — no significant VTE increase, unlike oral. Strongly preferred with migraine with aura, hypertriglyceridemia, obesity, diabetes, gallbladder disease, or any VTE risk factor.

Titrate by symptoms at 4–8 week intervals.

⚠️ Femring is systemic and needs progestogen opposition. Estring is not and does not. This is the most common point of confusion in the category.

Progestogen opposition — required for every woman with a uterus on systemic estrogen

• Micronized progesterone 200 mg qhs × 12 days/cycle (the FDA-approved regimen) or 100 mg nightly continuously (off-label, widely used). Preferred over synthetic progestins — lower breast cancer signal. Contains peanut oil — contraindicated in peanut allergy, generics included.
• MPA 10 mg × 12–14 d/month, or 2.5 mg daily continuous
• Norethindrone acetate 5 mg × 12 d, or 0.5–1 mg daily
• LNG-IUS 52 mg (Mirena, Liletta) — effective, off-label for this in the US, ideal in perimenopause when contraception is also wanted
• Duavee (CEE 0.45/bazedoxifene 20 mg) needs no progestogen — bazedoxifene protects the endometrium
• Not needed with low-dose vaginal estrogen

Bleeding to expect: cyclic → predictable monthly withdrawal bleed. Continuous-combined → goal is amenorrhea, but breakthrough bleeding is common for the first 3–6 months. Use cyclic within 1–2 years of the FMP, then switch to continuous.

If you skip opposition: endometrial hyperplasia → carcinoma. This is the one risk FDA kept in the box, and the most defensible malpractice claim in the field. Hard stop: systemic estrogen + intact uterus must have documented endometrial protection.

POI / early menopause is different — this is replacement, not treatment. Doses are higher, therapy is not optional regardless of symptoms, and it continues to age ~50–52, then is reassessed like anyone else.

• Transdermal estradiol 75–100 mcg/24 h, or oral estradiol 2–4 mg, or CEE 0.625–1.25 mg
• Micronized progesterone 100–200 mg × 12–14 days per cycle (or MPA 10 mg, or LNG-IUS) — the estrogen dose is what goes up in POI, not the progestogen
• HT is not contraception — spontaneous ovulation occurs in 5–10% of POI. Address contraception separately.

MHT — Non-Hormonal for Vasomotor Symptoms

• Do not initiate either NK antagonist if ALT/AST ≥2× ULN or bilirubin ≥2× ULN. Stop if transaminases >5× ULN, or >3× ULN with bilirubin >2× ULN.
• Fezolinetant: contraindicated with cirrhosis, eGFR <30, or any CYP1A2 inhibitor (fluvoxamine, ciprofloxacin, mexiletine). Regional supply has been inconsistent — check availability before starting.
• Elinzanetant: contraindicated in pregnancy; avoid strong CYP3A4 inhibitors/inducers and grapefruit; dose-reduce to 60 mg with moderate inhibitors. Better for sleep (NK1 blockade) — pick it when insomnia dominates.
• Avoid paroxetine and fluoxetine with tamoxifen (CYP2D6).
• CBT and clinical hypnosis are the only behavioral therapies TMS recommends. Explicitly not recommended: paced respiration, herbals/supplements, soy/equol, exercise alone, yoga, mindfulness, acupuncture, cannabinoids, and clonidine.

Genitourinary Syndrome of Menopause

Load daily × 2 weeks, then maintain twice weekly, indefinitely — symptoms return within weeks of stopping. There is no taper.

Use 0.5–1 g of cream — the legacy 2–4 g label dose is far more than needed.

• No progestogen and no endometrial surveillance with low-dose vaginal estrogen. But any bleeding gets a full workup.
• Recurrent UTI: vaginal estrogen is a Grade B recommendation (AUA 2025) and is badly underused — 0.5 vs 5.9 UTIs per patient-year in the classic trial.
• CO₂ laser, Er:YAG, and radiofrequency are not supported. Do not offer them.
• Breast cancer survivors: non-hormonal first (lubricants, moisturizers, hyaluronic acid, pelvic floor PT). If that fails, low-dose vaginal estrogen may be used including on tamoxifen. On an aromatase inhibitor, requires documented shared decision-making with oncology. Note the label still lists breast cancer as a contraindication — this is society-supported off-label use. Document it.

MHT — Monitoring

Baseline: history and exam for contraindications, BP, current mammogram and cervical screening. No hormone levels are needed to diagnose menopause or start HT in a woman over 45 with a typical picture. FSH/estradiol only for suspected POI (<40), ambiguous cases <45, or post-hysterectomy.

Do not routinely follow serum estradiol. There is no validated target for symptom relief, immunoassays are unreliable at postmenopausal levels, route changes the kinetics, and checking invites escalation toward a number instead of a symptom. Exceptions: apparent non-response on adequate transdermal dosing, suspected non-adherence, or confirming a patient transferred off pellets is back in range.

• Reassess at 3 months after starting or any dose change; then annually, BP every visit
• After 60, explicitly re-weigh risk-benefit annually and consider stepping the dose down
• Mammography per standard screening — but counsel that EPT raises density and callback rates
• HT does not need to be stopped at 60 or 65. No arbitrary stop date (TMS 2022).
• Stopping: taper over 3–6 months (step the patch down one strength q4–8 wk) — same 1-year recurrence rate as abrupt, but a gentler rebound. Keep the progestogen on board as long as any systemic estrogen is. Vaginal estrogen continues separately and indefinitely.

Postmenopausal bleeding — ACOG changed this in April 2026. Initial evaluation should now include TVUS and endometrial sampling in most patients. The ≤4 mm cutoff stands but its NPV is lower than previously taught and does not exclude serous or clear cell histology. TVUS-only triage is acceptable only with all of: single episode, fully visualized endometrium ≤4 mm, no risk factors, and reliable follow-up.

Compounded Hormones & Pellets — Why Not

ACOG, the Endocrine Society, TMS, and NASEM are unanimous: do not use compounded hormones when an FDA-approved equivalent exists.

The line that ends the conversation: “bioidentical” is a marketing term, not a chemical or regulatory one — and FDA-approved bioidentical products already exist. 17β-estradiol in every route, micronized progesterone, and Bijuva are all structurally identical to endogenous hormone and made under FDA quality oversight.

Pellets are the worst version of this:

• Supraphysiologic levels, often several-fold above the female range
• Zero-order release — not titratable and not removable. A VTE or an unexplained bleed on day 10 means months of continued exposure.
• FDA found one pellet firm had failed to report over 4,000 adverse events; of those, FDA attributed roughly 61 to the pellets themselves (extrusion and cellulitis, 2013–2018), with breast cancer among reports found at a later inspection
• Irreversible androgenic effects in women — voice deepening, clitoromegaly, alopecia
• No FDA-approved estradiol or testosterone pellet exists for women in the US

Salivary hormone testing is rejected by every society. Using it to justify dose escalation is a documented deviation from standard of care.

Handling a patient who arrives on pellets: don’t shame them. Let the pellet wear off, transition to an equivalent FDA-approved regimen, and check a level then to confirm they are back in range.

Testosterone Therapy in Men — Diagnosis

Threshold: total testosterone <300 ng/dL, on TWO early-morning (7–10 am) FASTING measurements on separate days, using a CDC HoST-certified assay. This is the AUA’s strongest recommendation (Grade A) and the one most often skipped.

Why two: diurnal variation (afternoon draws read 20–30% low), large within-person biologic and analytic variability, glucose acutely suppresses testosterone, and acute illness or sleep deprivation suppress the axis. Defer testing during acute illness.

Levels alone are not a diagnosis, and symptoms alone are not a diagnosis — you need both. (Endocrine Society, July 2026: “symptoms alone are not diagnostic of hypogonadism.”)

Free testosterone only when total is borderline (200–400 ng/dL) or an SHBG-altering condition is present. Use equilibrium dialysis or a calculated free T from total + SHBG + albumin. Direct analog immunoassays are unreliable — do not use them.

The obese diabetic middle-aged man — the archetypal TRT request — has low SHBG, so his total under-represents bioavailable androgen and his free T is often normal. This is the leading cause of over-diagnosis.

Required workup before treating

• LH ± FSH — separates primary (↑LH) from secondary (↓/normal LH). Grade A.
• Prolactin if LH is low or low-normal. Grade A.
• Hct, PSA (if >40), DRE, iron studies, TSH, BP, lipids
• Semen analysis if fertility matters now or later
• Pituitary MRI if T <150 ng/dL, persistent hyperprolactinemia, panhypopituitarism, or mass-effect symptoms/visual field changes

Treat the reversible causes first — this is the whole difference between a practice and a low-T clinic

Real-world benchmark (ENDO 2026, 200 men): only 12% had a guideline-concordant workup. That is the standard you are being measured against.

TRT — Contraindications & Formulations

Do not start: breast or prostate cancer · PSA >4.0 (or >3.0 if high risk) without urologic evaluation · unevaluated prostate nodule · Hct >48% (>50% at altitude) · untreated severe OSA · uncontrolled or severe HF · within 3–6 months of MI or stroke · thrombophilia · uncontrolled hypertension · any desire for current or future fertility.

FDA label status (2026): the cardiovascular language was removed from the boxed warning class-wide in Feb 2025 after TRAVERSE, and a blood pressure warning was added — then de-boxed to Warnings & Precautions in July 2025. The only boxed warnings left are secondary exposure/virilization in children (gels) and POME/anaphylaxis (Aveed). Testosterone remains Schedule III — a Dec 2025 FDA panel recommended de-scheduling but nothing has changed.

⚠️ Gel transference is the surviving boxed warning. Wash hands, cover the site once dry, wash the site before skin-to-skin contact. Document the counseling — this is a genuine liability exposure in a household with young children.

TRT — Targets, Monitoring, Adverse Effects

Target: total testosterone 450–600 ng/dL (mid-tertile of normal). Do not target the upper end and never above the reference range — no added benefit, clear added harm.

When to draw: weekly injection → trough, day 7, immediately before the next dose. Gel → morning pre-dose, day 14 and 28. Oral → 6 h post-AM-dose for Jatenzo, 3–5 h for Kyzatrex. Pellets → ~1 month and near end of interval.

Document an annual reassessment of whether therapy is still indicated. If there is no symptomatic benefit after 3–6 months at target, stop.

Erythrocytosis — the most common actionable AE. Don’t start if Hct >48%. At Hct ≥54%, act. In order: (1) reduce the dose or split it more frequently — first line and best supported; (2) switch IM→SC (Hct 46.3% vs 48.4%) or to a gel/nasal; (3) treat OSA, stop smoking; (4) hold until normalized, restart lower; (5) therapeutic phlebotomy last — the evidence for it is poor and it may paradoxically raise thrombotic risk via iron depletion and reactive EPO, plus it causes iron-deficiency symptoms.

PSA → refer to urology for a confirmed rise >1.4 ng/mL above baseline, a confirmed PSA >4.0, or any new nodule. A small early rise (<0.5) in the first 3–6 months is physiologic re-androgenization.

Other: gynecomastia → reduce dose, increase frequency, or switch IM→SC (SC estradiol 33 vs IM 47 pg/mL) — not anastrozole. Evaluate any unilateral, hard, or fixed mass for male breast cancer. Acne, edema, worsening OSA, BP rise ~4–5/1.5–2.5 mmHg, mood change.

TRAVERSE in one line: MACE-neutral (HR 0.96) in men who genuinely met criteria — but atrial fibrillation 3.5% vs 2.4%, AKI 2.3% vs 1.5%, and pulmonary embolism 0.9% vs 0.5% (a numerical imbalance, no published relative risk). A fracture signal appeared in a separate NEJM substudy, not the primary CV paper. It is not an all-clear, and it says nothing about men with normal levels or supraphysiologic dosing.

Fertility. Exogenous testosterone drops intratesticular testosterone ~100-fold → azoospermia. Recovery takes 6–24 months and is not guaranteed.

• Wants testosterone AND fertility → clomiphene 25–50 mg daily (or every other day) is the cleanest answer in secondary hypogonadism — raises testosterone while preserving spermatogenesis. Useless in primary hypogonadism.
• If TRT is used anyway: add hCG 500 IU SC every other day, semen analysis q3–6 months
• Conception within 6 months: stop TRT, hCG 3000 IU every other day, semen analysis q2 months
• Offer sperm cryopreservation to any man who might want future fertility before the first dose. Cheap, definitive, and the strongest defense against the AUA/ASRM standard.
• hCG is no longer compoundable — it transitioned to biologic licensure in March 2020. Use an FDA-approved product labeled for men — Pregnyl or Novarel (Ovidrel is labeled only for ovulation induction in women); supply is intermittent, $80–$400/vial.
• Anastrozole: do not use routinely. 1 mg daily for a year lowered spine BMD (p=0.0014) — estradiol, not testosterone, drives male bone. Reserve 1 mg twice weekly for symptomatic gynecomastia with confirmed high estradiol after dose and formulation changes have failed.

Testosterone in Women

One evidence-based indication only: postmenopausal HSDD. Not fatigue, mood, cognition, bone, muscle, or “low T” — none are supported.

• A testosterone level should not be used to diagnose HSDD. Levels are drawn for safety monitoring, not case-finding. This is the single most violated principle in commercial hormone practice.
• No FDA-approved female product exists in the US. Use one-tenth of the male starting dose of a 1% transdermal gel ≈ 5 mg/day — about 3 tubes a month instead of 30. Apply to lower abdomen or outer thigh.
• Target: physiologic premenopausal female range, ~27–57 ng/dL. Never exceed the female upper limit.
• Baseline total testosterone AND SHBG, LFTs, lipids. Level at 3–6 weeks, repeat within 6 weeks of any increase, then q4–6 months.
• Voice deepening and clitoromegaly are irreversible — stop immediately. Check for acne, hirsutism, scalp thinning at 6 months and annually.
• Effect at 6–8 weeks, maximal ~12 weeks. No meaningful benefit by 6 months → stop.
• Avoid pellets, IM injections, oral testosterone, and troches in women.

Obesity & Weight Management

Eligibility (all agents): BMI ≥30, or ≥27 with a weight-related comorbidity (HTN, T2DM, dyslipidemia, OSA, CVD).

Workup before prescribing — this is what separates medical weight care from a program: TSH, A1c and fasting insulin, lipids, LFTs, CMP; a medication review (several common prescriptions drive steady weight gain and swapping one is sometimes the whole intervention); and screening for OSA, PCOS, hypothyroidism, and prediabetes.

Head to head (SURMOUNT-5, 72 wk): tirzepatide −20.2% vs semaglutide −13.7%.

Practical

• Orforglipron has no food, water, or timing restrictions — the adherence advantage. Oral semaglutide requires waking, ≤4 oz plain water, and nothing for 30 minutes.
• Stop rules: Qsymia — stop if <5% loss at 12 wk on 15/92. Contrave — stop if <5% at 12 wk at maintenance.
• Qsymia taper: 15/92 every other day × ≥1 wk before stopping (seizure risk). Teratogen — contraception and pregnancy testing.
• Contrave contraindicated in uncontrolled HTN, seizure, eating disorder, chronic opioid use, MAOI within 14 d. Phentermine contraindicated in CVD, hyperthyroidism, glaucoma, substance use history, pregnancy.
• GI side effects: slow the titration (extend a step 2–4 wk), smaller low-fat meals, stop at first fullness, hydrate, scheduled PEG, ondansetron PRN.
• Boxed warning, all GLP-1/GIP: thyroid C-cell tumors — no personal or family history of MTC or MEN2. Also pancreatitis, gallbladder disease, gastroparesis, retinopathy worsening. Never combine two GLP-1 RAs.
• Muscle matters. Rapid loss costs lean mass — protein intake and resistance training are part of the prescription, not an afterthought.
• Stopping means regain. Frame it like hypertension from the first visit.
• Compounded semaglutide and tirzepatide are no longer defensible. Shortages resolved in 2025; in April 2026 FDA proposed excluding all three GLP-1s from the 503B bulks list and expressly rejected affordability as a clinical need. The 503B pathway is closed; 503A survives only for genuinely patient-specific compounding and still faces the “essentially a copy” bar. Approved self-pay pricing has converged close enough that the legal risk buys almost nothing.

Peptides & Anti-Aging Requests

Patients arrive with printouts. A consistent, evidence-cited “no” is both better medicine and better risk management than case-by-case improvisation.

⚠️ Growth hormone is the bright line — 21 USC §333(e) makes off-label GH a FELONY, 5 years (10 if the recipient is a minor), with DEA investigative authority and asset forfeiture. Distribution of GH for any use other than an indication FDA has affirmatively approved is criminal — a near-unique carve-out in US drug law. A physician’s prescription is not a defense; FDA treats writing it as “distribution.” The statute defines GH as “somatrem, somatropin, or an analogue of either” — so the secretagogue workaround does not clearly escape it. Do not prescribe GH for aging, body composition, performance, or a low-normal IGF-1.

Compounding status (as of Aug 2026). Only Category 1 substances fall under FDA’s enforcement-discretion policy. In Sept 2023 FDA put 19 peptides in Category 2 (safety risk identified). In April 2026 it removed 12 from Category 2 — but stated plainly that removal “does not render these bulk drug substances eligible for compounding.” A July 2026 advisory committee recommended Category 1 for six, overriding FDA’s own scientists; formal rulemaking takes 12–24+ months. As of August 2026 nothing in this group sits in Category 1 — GHK-Cu was itself removed from Category 1 in April 2026 when its nomination was withdrawn, and is pending PCAC review. Re-check the FDA bulks list before any decision — the next tranche is due Feb 2027.

California exposure. B&P §2238 makes a violation of any federal drug statute or regulation independently unprofessional conduct — no patient harm required. §2234(e) covers dishonesty (marketing claims that outrun the evidence). §2242 covers prescribing without a good-faith prior exam. §725 covers excessive prescribing. And the clinic’s own website is discoverable and is usually the strongest evidence against a cash practice. Confirm in writing whether the malpractice carrier covers non-FDA-approved therapies before offering any of this.

Safe posture: prescribe the approved product where one exists · never GH outside a labeled indication · treat “removed from Category 2” as not permission · decline the Category 2 holdovers outright · refuse to supervise research-chemical use · document indication, alternatives, absent outcome data, risks, and monitoring for genuinely off-label approved drugs.

Consent & Monitoring Templates

Copy into the note. The documentation is the defense.

MHT — consent elements

☐ Symptoms and severity documented · ☐ Within the window (age <60 or <10 yr from FMP) — or justification if not · ☐ Contraindications reviewed: breast cancer, VTE, stroke/MI, liver disease, thrombophilia, unexplained bleeding · ☐ Uterus present → endometrial protection prescribed, agent and regimen named · ☐ Transdermal offered and rationale for route documented · ☐ Discussed: breast cancer risk with EPT, VTE risk by route, stroke, and that benefits generally outweigh risks within the window · ☐ Non-hormonal alternatives offered · ☐ Told to report any unscheduled bleeding · ☐ Mammogram and cervical screening current · ☐ Baseline BP · ☐ Reassessment at 3 months, then annually

TRT — consent elements

☐ Two early-morning fasting levels documented, with the assay named · ☐ Symptoms documented · ☐ LH ± FSH ± prolactin · ☐ Reversible causes assessed: weight, OSA, opioids, alcohol, glucocorticoids, thyroid, prior AAS · ☐ Contraindications screened: Hct, PSA, DRE, OSA, HF, VTE, prostate/breast cancer, recent MI/stroke · ☐ Fertility discussed and cryopreservation offered · ☐ Off-label status documented if SC cypionate · ☐ Transference counseling if gel · ☐ Target 450–600 ng/dL stated, with the monitoring schedule · ☐ Discussed: erythrocytosis, PE and AF signals from TRAVERSE, BP rise, acne, gynecomastia, OSA worsening, infertility · ☐ Schedule III — CURES checked

Lab monitoring at a glance

Cash Pricing for These Services

Self-pay estimates, August 2026. Direct-to-consumer labs run 5–10× cheaper than retail — know the floor before you quote.

Labs (Own Your Labs / DiscountedLabs, Labcorp-based)

The same build at Labcorp OnDemand or Quest direct runs $500–650.

Men’s TRT

Women’s HRT

Vaginal estrogen prices vary several-fold between the discount-card price and the shelf price — always run the card before telling a patient what it costs, because the quoted retail number is what stops them from filling it.

Weight loss (manufacturer direct self-pay)

Prices in this category re-price every few months — verify before quoting.

Regional benchmark: SoCal men’s health clinics charge $199 initial consult and $150–500/mo for a TRT program; weight-loss programs cluster $99–348/mo including medication. The market is split between national telehealth at $99–199/mo with minimal clinical contact and physician-led local clinics. A cash family practice competes on the exam, the relationship, and honest scope — declining peptides is a differentiator, not a lost line, because it is the one thing the telehealth competitors cannot credibly claim.

Laceration Repair

Over a joint: go one size heavier, leave in at the long end, and splint.

Anesthetic maximums

• Lidocaine plain: 4.5 mg/kg, max 300 mg = 30 mL of 1%
• Lidocaine with epi: 7 mg/kg, max 500 mg = 50 mL of 1%
• Epi is safe in digits, nose, and ears at commercial concentrations — the old prohibition is obsolete
• Reduce sting: buffer 1:10 with 8.4% bicarb, warm the vial, 27–30 g needle, inject slowly through the wound edge

Tissue adhesive if ALL: <12 h, linear, hemostatic, low tension, not across a joint or mucocutaneous junction, not hair-bearing, not contaminated, not a bite. Cosmetic outcome equals sutures at 3 months.

Do not close: cat bites (47–58% infection — except face), dog/human bites to the hand, puncture wounds, grossly contaminated wounds. Clean wounds may be closed up to 18 h (scalp/face 24 h); beyond that, delayed primary closure at 3–5 d. Refer: open fracture, tendon or nerve injury, salivary/lacrimal duct, eyelid deeper than subcutaneous. Prophylactic antibiotics (amox-clav; clindamycin if allergic) for cat bites, deep punctures, wounds >3 cm — not for simple lacerations.

Tetanus

Abscess I&D

• Field block around the periphery (not into the cavity — acidic pus blunts lidocaine), #11 blade along tension lines across the full length of maximal fluctuance, break loculations with a hemostat, irrigate. Bedside ultrasound settles cellulitis vs abscess.
• Packing is not supported for simple abscesses <5 cm — more pain, more visits, no benefit. Reserve for large, deep, or pilonidal.
• Loop drainage: two 5 mm stab incisions at opposite poles, blunt tunneling, vessel loop tied loosely, patient removes at 7–10 d. Equal or better cure, smaller scar, no packing changes.
• Antibiotics after I&D: TMP-SMX DS BID (preferred over clindamycin — BID and less GI). Cephalosporins add nothing.

Ingrown Toenail

• Digital block: 1–2% lidocaine with epi 1:100,000. Three passes — medial subcuticular toward plantar, lateral across the dorsum, lateral subcuticular toward plantar; 1–2 mL each on withdrawal. Wait 5–10 min.
• Partial nail avulsion: elevate the lateral edge with a hemostat, split the lateral ≥30% from distal to under the cuticle (under-resection drives recurrence), grasp and avulse distally with rotation, inspect the sulcus for spicules.
• Phenol matrixectomy: 80–88% phenol on a cotton applicator to the exposed matrix, 2–3 applications of 30–60 s, dry bloodless field, then irrigate with alcohol or saline. Drops recurrence to 1–4% (vs ~38% without). Skip only for arterial insufficiency or active infection.
• No routine antibiotics — not even with granulation or purulence from the nail itself. Only for spreading cellulitis.
• Expect sterile exudate 2–3 weeks.

Other Procedures

Subungual hematoma: trephinate any painful acute hematoma within 48 h, regardless of size. Electrocautery or an 18 g needle rotated like a drill; block usually unnecessary. Remove the nail only if the plate is avulsed, the fold is disrupted, or the phalanx fracture is displaced.

Corneal foreign body / abrasion: visual acuity first, always. Proparacaine → fluorescein under cobalt blue. Evert the upper lid — vertical “ice-rink” abrasions mean a retained FB under it. Seidel sign → immediate ophtho, shield, no pressure. Remove with a moist swab, then an eye spud or 25 g needle held tangential under magnification. Rust ring can wait 24 h. Never send home with topical anesthetic. Don’t patch. Contact lens wearers get antipseudomonal drops and daily recheck.

Ear/nose FB: alligator forceps for graspable, a curette passed beyond and withdrawn for smooth spheres. Live insect — kill it with viscous lidocaine or mineral oil first. Don’t irrigate organic material (it swells) or a perforated TM. Nose: “parent’s kiss” positive pressure first. Button batteries and paired magnets are emergencies. Each failed attempt lowers the odds of the next — refer early.

Epistaxis: blow out clots → sit up, lean forward, pinch the soft lower third for a full 10 minutes without peeking → oxymetazoline pledget + repeat compression → anterior rhinoscopy with suction → silver nitrate cautery, one side of the septum only → packing (resorbable if anticoagulated). Do not stop or reverse anticoagulation as a first move. Prevent with saline gel and humidification.

Nursemaid’s elbow: hyperpronation — 90.8% first-attempt success vs 73.6% for supination-flexion, and less painful. Thumb over the radial head, forcefully pronate the forearm. Child uses the arm within 5–15 min. No sling. Two failures → x-ray.

Anterior shoulder dislocation: document axillary nerve before and after. Low-force first — scapular manipulation (90–97%, pain ~1.5/10) or FARES (88–95%) or Cunningham (no sedation). Traction-countertraction needs sedation and carries the highest complication rate. First dislocation under 25 → refer, very high recurrence.

Cerumen: treat only symptomatic impaction or when it blocks exam. Cerumenolytic, irrigation, or manual removal — none superior. Don’t irrigate with suspected perforation, tubes, prior ear surgery, diabetes, immunocompromise, anticoagulation, or radiation — use manual removal. Discourage swabs and ear candling.

BPPV: Dix-Hallpike (head 45° toward the tested ear, lay supine with neck extended 20°, hold 30 s) → latent, transient, fatigable upbeating-torsional nystagmus. Treat with Epley; no postural restrictions afterward. Horizontal or no nystagmus → supine roll test for lateral canal. Don’t image, and don’t use meclizine or benzodiazepines — they delay central compensation. Recheck within a month.

Injections

• Recent evidence: 20 mg triamcinolone works as well as 40.
• No more often than every 3 months at the same site; 3–4 per joint per year.
• Mix roughly 1 part steroid : 3–5 parts 1% lidocaine for a large joint. Lidocaine gives immediate diagnostic feedback. Prefer lidocaine over bupivacaine intra-articularly (chondrotoxicity).
• Don’t mix particulate steroid with chlorhexidine; never inject through infected skin. Hip needs image guidance.

Trigger point injections: no agent beats another or placebo — reserve for myofascial pain refractory to massage, PT, and manual therapy. 1–2 mL of 1% lidocaine per point, fanning 0.3–0.5 mL per pass, 1–4 points per session. Corticosteroid adds nothing. 25–27 g × 1.25–1.5″ (21 g spinal for deep/obese). Reassess at 4 days; abandon after 2–3 failures. Expect 2–4 months of benefit; 3–4 days of post-injection soreness is normal.

Splinting

New Patient Baseline Labs

CBC · CMP · lipid panel · HbA1c · TSH · vitamin D · UA Add by risk: HIV, HCV, RPR, UACR (all hypertensives and diabetics), Lp(a) once in a lifetime, ferritin/iron, testosterone, PSA (shared decision 55–69).

USPSTF Adult Screening (A/B)

Colorectal strategies: FIT annually · sDNA-FIT (Cologuard) q1–3 yr · colonoscopy q10 yr · CT colonography q5 yr · flex sig q5 yr (or q10 yr + annual FIT). Any abnormal non-colonoscopy test → colonoscopy.

Note: cervical self-collection HPV is FDA-approved and endorsed by ACS, ASCCP, and ACOG, but the USPSTF recommendation is still the 2018 version — so first-dollar coverage isn’t guaranteed. For a cash panel this matters less; it’s a genuinely useful option for patients who decline a speculum exam.

Adult Immunization (2026)

• Influenza — annual, all adults. ≥65: prefer high-dose, recombinant, or adjuvanted.
• COVID-19 — 19–64: ≥1 dose of current formulation; ≥65: 2 doses ~6 mo apart. Expect payer inconsistency in 2026; confirm locally.
• RSV — ≥75 routine, single dose. 50–74 if increased risk (chronic cardiac/lung disease, ESRD, diabetes with complications, chronic liver disease, BMI ≥40, immunocompromise, nursing home). Not annual — one dose. Best given Aug–Oct. Pregnancy: Abrysvo × 1 at 32–36 wk, Sept–Jan.
• Pneumococcal — age threshold is now 50 (was 65). Naïve: PCV20 × 1 or PCV21 (Capvaxive) × 1 or PCV15 → PPSV23 ≥1 yr later. PCV13 is no longer recommended for adults. Ages 19–49 with smoking, alcohol use disorder, CSF leak, cochlear implant, chronic heart/liver/lung disease, DM, HIV, asplenia, or immunosuppression.
• Zoster (Shingrix) — ≥50: 2 doses 2–6 months apart. 19–49 immunocompromised: 2 doses 1–2 months apart. Give regardless of prior shingles or Zostavax.
• Tdap/Td — Tdap once if never had it, then q10 yr. Tdap every pregnancy, 27–36 wk.
• HPV — routine through 26. Two doses if started 9–14; three if started ≥15 or immunocompromised. Shared decision 27–45.
• Hepatitis B — universal 19–59; ≥60 by risk or request.

The January 2026 HHS schedule revisions were stayed by federal injunction in March 2026 — the prior (January 2025) schedule governs. Verify before a mass ordering decision.

Other Prevention

• BMI at every visit — and act on it (see Obesity)
• Tobacco: ask, advise, and offer varenicline or NRT at every visit
• Alcohol: AUDIT-C; brief intervention
• Falls in ≥65: exercise + vitamin D; review meds
• Aspirin: no longer routine for primary prevention — individualize under 60 with high CV risk and low bleeding risk

Under $10 — quote these freely

The pitch you can make honestly: a patient’s blood pressure, cholesterol, diabetes, thyroid, and antidepressant together run under $35/month.

The expensive ones — script the conversation

Never write a prescription for: cetirizine, loratadine, famotidine, or plain ibuprofen — store brand OTC is cheaper than any prescription channel.

GLP-1 Cash Pricing (2026)

In-Office Dispensing in California

No pharmacy license or permit required. BPC §4170 — all seven conditions must hold:

• Dispensed to your own patient (a nurse or attendant may not dispense; PA/NP may hand out pre-labeled prepackaged drugs)
• Necessary for the current condition
• You do not keep a pharmacy, open shop, or drugstore — dispensing incident to a visit is fine; a walk-in fill counter is not
• Full §4076 labeling, recordkeeping, and child-resistant containers
• You personally own any automated dispensing device and its contents
• You offer to give a written prescription they can fill elsewhere
• You give written notice they may fill with you or at any pharmacy

Label (16 CCR §1707.5): four elements in a primary label area covering ≥50% of the label, ≥12 pt sans serif, in order — patient name · drug name and strength · directions · condition or purpose. Elsewhere: prescriber, date, dispensing site name/address, Rx number, quantity, expiration, physical description. Directions must be available in five non-English languages (Board of Pharmacy publishes the official translations). Keep records ≥3 years. Store drugs in a secure area (§4172).

Controlled substances: report Schedule II–V to CURES within one working day. (Gabapentin is not scheduled in California.)

Practical build-out: buy from a physician-dispensing repackager (Proficient Rx, MDScripts, A-S Medication Solutions) that ships pre-labeled unit-of-use bottles with a compliant dispensing log — far easier than building the label workflow yourself.

Highest-yield in-office stock (all under ~$10 acquisition, so a flat $10–15 dispense fee is a patient bargain and margin-positive): cephalexin · amox-clav · doxycycline · azithromycin · TMP-SMX · nitrofurantoin · metronidazole · fluconazole 150 · valacyclovir · prednisone · methylprednisolone dose pack · ondansetron ODT · mupirocin · triamcinolone cream · meloxicam · cyclobenzaprine · Depo-Provera 150 mg vial ($16.50).