Hello Reno Families!

This is Leslie Greenberg.  I am a family physician in Reno, Nevada.  I attended University of Nevada School of Medicine and relocated back to my hometown in 2015.  I trained and practiced medicine in the Midwest (Indiana and Kansas) for 20 years before moving back West.  I consider myself a teacher and educator.  I  have  taught family medicine residents for 20 years.  I currently teach at the family medicine residency program in Reno and also see private patients.  I invite you to read my blog.  If you would like to become a patient, please call 775-682-8200.

Medical Disclaimer

Please remember that medical information provided by myself, in the absence of a visit with a health care professional, must be considered an educational service only.  This blog should not be relied upon as a medical judgement and does not replace a physician’s independent judgement about the appropriateness or risks of a procedure or condition for a given patient.  I will do my best to provide you with information that may help you make your own health care decisions.

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Can you afford your medications?

One of the reasons that patients do not fill their prescriptions are due to increasing medication costs. 

I have begun asking my patients “Is the cost of any of your medications a burden for you?”  This fast screening question at the time of your visit helps greatly.  Physicians or medical assistants should review the medicines you currently take.

What can you do?

  1. Have your physician review your medications
  2. Do you still need to take the medication?
  3. Can you change to a less expensive medication or a generic version?
  4. Consider using a 90-day prescription to reduce copayments.  As an aside, this may also increase ease of use in that having medications at the house is easier than going to the pharmacy every month.
  5. Look up the medicine online to find the name of the manufacturer.  Then, see if there is a discount program with the pharmaceutical manufacturer for that medicine.  At times these discount programs are easy to complete and some require your tax return from the year before.
  6. Look online to see if your medication is available at a large chain pharmacy on their “$4/month list.” 
  7. Use websites and apps such as singlecare.com or goodrx.com that provide comparative costs between pharmacies and coupons for prescription medications
  8. Consider cutting a stronger medication in ½ (to get the desired strength).
  9. Does your physician’s office have a social worker to help navigate these issues?

At our family medicine residency office, we have a social worker who helps patients who need more intensive support (such as navigating insurance plans, determining eligibility for additional insurance coverage, and applying for pharmaceutical medication assistance programs).  

I hope this helps.

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Questions about managing elevated cholesterol…

Managing cholesterol can feel like this…

Questions about managing elevated cholesterol…

Primary prevention means preventing the FIRST EPISODE of a cardiovascular event (like a stroke or heart attack).  Primary prevention is key!  Family physicians make treatment decisions based on clinical risk and risk calculators.  Try this link to find your risk: ASCVD risk calculator

What influences the score on the risk calculator?  Obesity, high blood pressure, diabetes and tobacco use influence risk scores significantly more than cholesterol values. 

Who should get a coronary artery calcium score?  Consider measuring this if you are 40-75 years of age (without diabetes and with an LDL less than 190) IF a decision about statin therapy is uncertain.  Coronary artery calcium scoring has not been shown to improve patient outcomes. 

Evidence supports moderate-dose statins as the BEST therapy in primary prevention for patients at increased risk with a mortality rate of 20-30% in 5 years.  Moderate-dose statin drugs are well tolerated with low risk of causing muscle breakdown or diabetes.  High-dose statins show similar cardiovascular benefits (although they have increased risk of causing diabetes or other side effects).  Ezetimibe sometimes is added to the statin but has not been shown to help much.  The goal of statins are to decrease LDL levels by at least 50%.

Who should start on a statin drug for primary prevention?  Patients with a 12% 10-year risk, or in diabetics with a 10-year risk of 6-12%, or in those with LDL of 190mg/dL or more.  Talk to your physician if your 10-year risk is between 6-12%

What should be done for secondary prevention?  Secondary prevention is when a patient has ALREADY had a cardiovascular event (heart attack, stroke, or needed a heart stent).  Moderate-dose statins are the mainstay of treatment. 

Who should start on a PCSK9 inhibitor?  Talk to your cardiologist if your LDL  (not your total cholesterol) is 220 or more, per American College of Cardiology/American Heart Association (ACC/AHA) recommendations.

Should you start on an omega-3 fatty acid to reduce cardiovascular disease risk?  No, research has not shown Omega-3 fatty acids to help.

What if you start on a statin drug and you have side effects?  Talk to your physician and consider stopping the statin.  After a washout period, re-challenge with a different statin or a lower dose.

How often should you have labs to check cholesterol after starting on medication?  The VA/Department of Defense suggests against routine monitoring whereas the ACC/AHA suggests checking 4-12 weeks after statin initiation or dose adjustment and then rechecking every 3 to 12 months, as needed.  Research shows that cholesterol levels are stable for up to 10 years, with most of the change between lab results due to testing variability.  Fasting before cholesterol labs are only needed to accurately evaluate high triglycerides.

I hope this helps.

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Do you need your vitamin D level checked?

Photo courtesy: Leslie Greenberg MD

Do you need your vitamin D level checked?   The US Preventive Services Task Force just weighed in on this and gave a “final recommendation statement.” 

Sounds impressive, huh?  Well, actually the USPSTF has said that to check vitamin D levels is an “I” recommendation.  This means that we have insufficient evidence to asses the balance of benefits of checking vitamin D level and harms of screening in asymptomatic adults.  Keep in mind that an A recommendation means we SHOULD do it.  B we PROBABLY SHOULD do it.  C recommendation that we should WEIGHT THE RISKS AND BENEFIT of checking.  D recommendation we SHOULD NOT do it.  And, then an “I” is insufficient evidence for or against.

Who does NOT need to have vitamin D checked? People who live in the community (versus a nursing home), non-pregnant adults, those with no signs or symptoms of vitamin D deficiency, or for those who do not have a condition requiring vitamin D.

Who may consider having vitamin D checked? Patients who are hospitalized or living in institutions (like nursing homes), those with a bone condition such as osteoporosis, osteomalacia or rickets.

Why should we not check?  Because we need more research on WHAT LEVEL of vitamin D people need to be healthy.  We do not know the level.

Generally, I suggest to patients that most of us have low or low-normal vitamin D levels.  We get vitamin D from the sun (but we are often indoors or outdoors wearing protective clothing) and from foods (fortified milk or salmon) but often we could use more.  Vitamin D3 is available over the counter, is inexpensive, and 2000 international units (IU) a day increases our levels.

I warn patients that oftentimes their insurance will not pay for Vitamin D labs and the patient should call her insurer to see what their “out of pocket cost for the vitamin D lab is.”  Insurers always know what they pay for… physicians don’t.

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HPV vaccine is REALLY effective!!!

HPV vaccine is REALLY effective!!!

The human papillomavirus vaccine is really effective, especially when given before age 17. 

There was a Swedish study of MORE than 1.6 million patients. The patients who received the vaccine before 17 were most helped. 

Incidence of invasive cervical cancer:

UNVACCINATED was 5.3 per 100,000 person-years.

VACCINATED was 0.73 per 100,000 person-years.

HPV is a vaccine that has been offered for more than 10 years.  Low side-effect profile.  Its use decreases the risk of cancer, just like the hepatitis B vaccine (we give to infants) decreases the risk of liver cancer.  Use of HPV vaccine does not increase risky sexual contact nor has it been shown to move up the timing of sex.

Want more information?  https://www.cdc.gov/hpv/parents/vaccine.html

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Who needs a tonsillectomy?

Who needs a tonsillectomy?

As a family physician, I send patients to ear nose throat surgeons for a tonsillectomy if …

  1. Seven throat infections in one year
  2. Five throat infections per year for 2 consecutive years
  3. Three throat infections per year for 3 consecutive years.
  4. Snoring or obstructed-breathing when asleep especially when associated with bed wetting, asthma, poor school performance or behavior issues.

(These are updated guidelines from The American Academy of Otolaryngology–Head and Neck Surgery)

As a side note, observational studies show that codeine (or any medication containing codeine) should not be given after tonsillectomy due to possible severe complications.

I hope this helps.

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Are you a woman with unwanted facial hair? Treatment is easy!

Are you a woman with unwanted facial hair? Treatment is easy!

Hirsutism is “excessive male-pattern hair growth in a woman.”  Hirsutism is common, as it affects between 5 and 10 percent of women of reproductive age.  Unwanted hair growth is associated with significant emotional distress and depression.

Why do women get hirsutism?  It is usually an indication of an underlying endocrine disorder, with the most common being polycystic ovarian syndrome. 

What to do? First-line treatment for women with unwanted hair (who are not trying to conceive) are combined oral contraceptives!  This is easy and well-tolerated therapy.  If facial hair does not get better after 6 months, then additional medication (an antiandrogen like spironolactone) can be started. 

Will it get better?  Yes!  But, probably will not completely go away… Reasonable expectations should be discussed. Medication is unlikely to completely eliminate already existing hair growth.  With time, hair may become less coarse, not grow as fast, and/or may require less frequent use of shaving, plucking, or waxing.

What can you do?  Talk to your doctor and they can write for combination oral contraception pills.  If you do not have a doctor, there is an online service, Pandiahealth.com , which links you to a physician who can send you in a years-worth of pills to your door. 

I hope this helps.

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Anaphylaxis: Life-threatening allergic reaction. What is this? What to do?

Anaphylaxis: Life-threatening allergic reaction.  What is this?  What to do?

Anaphylaxis is a life-threatening allergic reaction that usually occurs within 2 hours of allergen-exposure. 

This is pretty rare, but important to know the symptoms.  The two peak age ranges for anaphylaxis are in children (aged 2 to 12 years old) and in adults between 50 and 69 years.  Most anaphylactic reactions occur outside of the hospital.  Most common triggers are insect stings, foods, and medications.  Up to 20% of cases there is an unknown trigger.  Risk factors for anaphylaxis are those with older age, cardiovascular disease, peanut and tree nut allergy, and coexisting asthma.  

What makes it anaphylaxis?  And not just an allergic reaction?  Anaphylaxis involves TWO or more organ systems such as difficulty breathing (respiratory), tongue swelling (mucocutaneous), skin rash, reduced blood pressure (cardiovascular), abdominal pain/vomiting (GI).

What to do?  Remove the trigger first!  Epinephrine injected intramuscular (Epi-pen) and supportive care.  It is important that the patient continues to breathe, have a patent airway and have adequate circulation.  Only AFTER epinephrine is given should the adjunctive medications be considered. Do not rely on antihistamines (diphenhydramine) as first-line treatment in severe allergic reactions. Patients should be observed for 12 hours as a recurrence of anaphylaxis without re-exposure to the allergen may occur.

What are adjunctive medications?  H1 (diphenhydramine) and H2 blockers (like cimetidine, famotidine), steroids, albuterol nebulizer, and glucagon given in the vein.   

What to do AFTER an anaphylactic reaction?  Make an emergency action plan.  See an allergist.  Avoid triggers.  Always have an epinephrine auto-injector (epi pen) on hand.

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Hypertriglyceridemia. What is this? Is this important?

Burning Man art

Hypertriglyceridemia. What is this?  Is this important?

Hypertriglyceridemia is when the fasting serum triglyceride is 150 or more. 

Why is this important?  Hypertriglyceridemia is linked with an increase risk of cardiovascular disease.  If the triglycerides are more than 500, the risk of pancreatitis also increases.  Other risk factors for hypertriglyceridemia are metabolic syndrome, type 2 diabetes, and obesity.

How to manage hypertriglyceridemia?  If the level is less than 500, start with increasing exercise and change diet.  Good diets include low-carb and Mediterrean diet and the DASH (Dietary Approaches to Stop Hypertension) diet.   Avoid sugar-sweetened beverages.   Exercise promotes the muscle’s uptake of glucose and can reduce triglyceride levels. Moderate to high-intensity exercise and endurance exercise are especially helpful. Weight loss is important!  Even 5% weight loss is important.

If triglycerides are more than 500, your physician can calculate a 10-year risk of atherosclerotic cardiovascular disease.  If risk of heart attack or stroke (per the ASCVD risk calculator) is borderline (5 to 7.5%) or intermediate risk (7.5 – 20%) consider taking a statin medication.   If statins are not enough, then high-dose icosapent can reduce cardiovascular mortality (but only decreases 1 cardiovascular death over 5 years per 111 patients on the medication). 

Other medications which may help, but have not been studied thoroughly are fibrates, omega-3 fatty acids, and niacin. 

I hope this helps.

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Nevadans: Birth control (a years worth!) delivered to your door! Emergency contraception, too.

The Top 5 Legal Online Supplement & Prescription Services - Online Medical Care

Local news did a highlight about https://www.pandiahealth.com/ last night…


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Did you know that Nevada pharmacies are obligated by law to fill a years-worth of birth control pills at once?

Did you know that Nevada pharmacies are obligated by law to fill a years-worth of birth control pills at once?

Yes!  In 2018 Nevada legislature passed this bill…

NRS 689A.0418. This law requires a pharmacist to dispense up to a

12-month supply of drugs for contraception if:

1. The patient has previously received a three-month supply of the same drug;

2. The patient has previously received a nine-month supply of the same drug or a supply of the same

drug for the balance of the plan year in which the three-month supply was prescribed, whichever was


3. The patient is insured by the same health insurance plan for that year.

What can you do?  Ask your physician to refill your birth control pills for 13 pill packages with no refills.  The physician can cite Nevada NRS689A.0418 in their prescription to remind the pharmacist of the law requiring them to fill a years-worth at once.

Do you want a period monthly?  If so, take the pills as they are in the package (3 weeks of active pills and one week of inactive pills).

Do you want a period less than every month?  If so, take only the 3 weeks of active pills and then skip the placebo pills.  (For example, Then take the three weeks of active pills followed by the three active pills from the next pill pack followed by the three weeks of active pills from the third pack.  Then take the placebo pills and you will have a menstrual period once every 9 weeks).

Do you want to never have a menstrual period?  Take the three weeks of active pills of each pill pack and always skip the placebo pills.  You may have breakthrough vaginal bleeding, but this is not thought to be harmful.

If you do not have a doctor, https://www.pandiahealth.com/ is an online physician-led, woman-led service that can fill your birth control pills for a year.  Physician’s review your risks and which birth control pills may work well. Pandiahealth.com also will send emergency contraception, if wanted. 

I hope this helps.

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