Clinical question	Bottom-line answer	Clinical actions to consider for Choosing Wisely
Is confirmatory diagnostic testing cost-effective for the management of clinically suspected onychomycosis?A1	The most cost-effective approach to a patient with clinically suspected onychomycosis is empiric therapy with oral terbinafine (Lamisil). The chance of liver injury is estimated to be only one in 50,000 to one in 120,000, so testing to confirm the diagnosis would cost tens of millions of dollars per case of liver injury avoided. If you plan to prescribe the less effective and much more expensive topical solution efinaconazole (Jublia), then confirmatory testing with periodic acid-Schiff stain reduces costs.	If you are going to prescribe oral terbinafine, consider empiric therapy without confirmatory testing because it may be just as safe and is more cost-effective.
Is pregabalin (Lyrica) an effective treatment for the pain of acute or chronic sciatica?A2	Pregabalin does not relieve pain in patients with sciatica. This study randomized 207 patients with moderate to severe sciatica, and followed them for one year. The authors concluded that pregabalin does not relieve pain, improve function, or improve any other outcomes in patients with sciatica.	In patients with sciatica, do not routinely prescribe gabapentinoids such as pregabalin.
Do intra-articular corticosteroids improve pain and function and decrease cartilage loss in adults with osteoarthritis of the knee?A3	This well-done study found that regular three-month intra-articular injections of triamcinolone for two years resulted in no significant difference in pain and function assessments compared with saline. However, a significant increase in cartilage loss and damage occurred in patients receiving corticosteroids compared with saline.	In patients with knee osteoarthritis, do not routinely inject triamcinolone every three months to improve pain or function.
Is there a clinical benefit to treating subclinical hypothyroidism in older adults?A4	Treatment of patients with a minimally elevated thyroid-stimulating hormone (TSH) level did not result in any improvement in symptoms. If patients present with a TSH level between 4.6 and 10 mIU per L, repeat the test because levels often normalize (this occurred in 60% of the patients initially referred for the study). Only consider treatment if levels increase to greater than 10.0 mIU per L.	In adults 65 years and older, do not routinely treat subclinical hypothyroidism.
What is the best way to measure blood pressure?A5	To get the most accurate measure, let patients relax for a few minutes, and then measure their blood pressure on a completely bare arm. Does a difference of 4 mm Hg systolic and 6 to 7 mm Hg diastolic matter? It might, especially when deciding whether to add a second or third drug.	In older patients, do not measure blood pressure over an arm covered by a sleeve or with the sleeve rolled up.
Does home monitoring of blood glucose levels improve glycemic control or quality of life in patients with type 2 diabetes who are not taking insulin?A6	Lots of numbers, money, and strips in landfills, with little to show for it. Home glucose monitoring of patients in primary care does not improve A1C levels or quality of life over one year in patients who are not taking insulin. Patients did not feel more empowered or satisfied as a result of home monitoring, nor did they have fewer hypoglycemic episodes. Additionally, their physicians did not seem to respond to the home glucose levels to any beneficial effect.	In most persons with type 2 diabetes, do not routinely recommend home monitoring of blood glucose levels.
In patients with mild to moderate ankle sprain, does physical therapy (physiotherapy) hasten or improve recovery?A7	Physical therapy (up to seven sessions) does not hasten resolution of symptoms or improve function in adults with ankle sprain. Approximately 60% of patients who receive usual care or physical therapy do not achieve excellent resolution. Send patients home with the usual RICES protocol: rest, ice, compression, elevation, and splinting.	In adults with mild to moderate ankle sprain, do not refer all patients for physiotherapy.
Are gabapentinoids safe and effective in treating patients with chronic low back pain?A8	The existing data on gabapentinoids for chronic low back pain are limited in number and quality. The amount of pain reduction is low to moderate, whereras the rate of adverse effects is high. The few studies that assessed function found no improvement.	In adults with back pain of at least three months duration, do not recommend gabapentinoids to improve functional outcomes.
Does positive airway pressure for adults with sleep apnea reduce cardiovascular disease morbidity and mortality?A9	The use of positive airway pressure in adults with sleep apnea does not reduce adverse cardiovascular events or mortality. Patients who experience daytime fatigue at baseline benefit from reduced sleepiness and improved physical and mental well-being. Order sleep testing only in patients with signs or symptoms of sleep apnea who also experience clinically significant symptoms of daytime fatigue.	In adults with sleep apnea, do not recommend continuous positive airway pressure to reduce cardiovascular events or mortality.
When should treatment be initiated in older patients with hypertension, and what are reasonable goals?A10	Try to remember 60–150–140: In patients older than 60 years, consider treatment if the systolic blood pressure is 150 mm Hg or higher, or 140 mm Hg or higher in patients with a history of stroke or transient ischemic attack and in those at high cardiovascular risk. The guideline suggests initiating therapy only after a discussion of the benefits and risks with each patient; physicians should avoid making treatment decisions based just on the numbers.	In adults older than 60 years, do not routinely initiate antihypertensive treatment when systolic blood pressure is between 140 and 150 mm Hg.
How do older patients react to the idea of stopping cancer screening toward the end of life?A11	When bringing up the idea that cancer screening may no longer be beneficial given a patient's limited life expectancy, using direct language such as “You may not live long enough to benefit from this test” is perceived by many patients as overly harsh. Instead, statements such as “This test will not help you live longer” may be better received. Although not studied, this same approach may be helpful for deprescribing efforts.	In older patients, do not discuss the idea that cancer screening may no longer be beneficial using language such as “You may not live long enough to benefit from this test.”
Does screening of asymptomatic men for prostate cancer improve mortality?A12	There is still no evidence of mortality benefit from prostate cancer screening in the PLCO Cancer Screening Trial. After nearly two decades of follow-up from the PLCO Cancer Screening Trial, there appears to be no mortality benefit to screening asymptomatic men for prostate cancer. These findings are limited to some extent by contamination. (About one-half of the men assigned to no screening had at least one prostate-specific antigen test during the study period.)	In asymptomatic men 55 to 69 years of age, do not recommend screening for prostate cancer unless the patient understands the limitations of prostate-specific antigen screening and makes a personal decision that a small possibility of benefit outweighs the known risk of harms.
What is the long-term effect of intensive blood glucose control in patients with type 2 diabetes?A13	The initial Action to Control Cardiovascular Risk in Diabetes (ACCORD) study, which compared standard treatment (A1C target of 7.0% to 7.9%) with intensive control (A1C target of 6.0%), found that, despite good intentions, cardiovascular and overall mortality are significantly higher when blood glucose levels are lower. This study, which followed patients for an additional five years, found that patients in the intensive treatment group continued to keep their A1C levels lower than in the standard care group; however, they also continued to be at increased risk of death from a cardiovascular event.	In adults with type 2 diabetes, do not recommend intensive control of blood glucose to prevent cardiovascular disease.