Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to management of tremors in a kidney transplant recipient who is taking a CNI for immunosuppression?
This can be a really vesing problem for patients. My approach is somewhat dependent upon the severity of the tremors. I will sometimes try some low dose propranolol, 10 mg po BID-TID, or more often I will try converting from a the shorting acting forms of tacrolimus (Q12 hour formulations) to the lo...
What is your approach to evaluation and management of GERD in a patient with IPF?
When evaluating GERD in a patient with idiopathic pulmonary fibrosis (IPF), I prioritize obtaining a detailed history of GERD symptoms, as this aids in guiding both diagnostic and management decisions. Many IPF patients may not exhibit classic GERD symptoms like heartburn or regurgitation. Instead, ...
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
Do you wait on initiating biologic therapy for guttate psoriasis?
First, and foremost, it is important to identify the trigger for guttate psoriasis, which is often caused by step (which requires antibiotics). For most patients, a guttate flare will resolve on its own. When using biologics, we can help clear guttate psoriasis (note, this is largely based on anecd...
Do you check for EGFR and other mutations in patients with squamous cell lung cancer, including in adjuvant setting before considering immunotherapy?
Yes, I do. Our Cancer Institute performs NGS reflex testing for all patients with newly-diagnosed lung cancer, regardless of stage or histology. Although EGFR or other mutations are less common in squamous cell lung cancer, they do exist, and this also allows for testing for other mutations (MET exo...
When do you choose to switch to antidepressants vs augmentation in treatment-resistant depression?
When I approach depression that has been resistant to many antidepressant trials, I consider the following: First, I reassess the diagnosis. This includes considering comorbidities such as menopause symptoms, ED symptoms, exacerbation of chronic medical issues, and onset of MNCD. I ensure I have con...
What is your outpatient approach to monitoring paroxysmal atrial fibrillation (i.e. mobile cardiac telemetry, decision to anticoagulate if high likelihood of recurrence) in young adults with CHADsVASC score of 0, in light of potential remodeling and increased Afib burden as they age?
This is an important question, especially in light of the most recent data suggesting that early maintenance of sinus rhythm is beneficial in patients. If the patient truly has a CHADsVASC score of zero, they have lone atrial fibrillation, low stroke risk, and our major concern is prevention of remo...
Do you recommend starting anti-fungal prophylaxis for patients on systemic antibiotics who have a peritoneal dialysis catheter that is only currently being accessed for once weekly flushes?
This is a unique situation which is for me a strictly hypothetical one, as I've not encountered this situation in my 38-year PD career. Nor am I aware of data to guide a response. On reflection, however, I would answer in the affirmative. Fungal peritonitis is a very serious infection which invariab...
What is the best treatment option for a patient with bipolar disorder, who stopped her medication at the start of pregnancy and is now at the end of 2nd trimester?
This is a great question. Restarting medication would be a top priority, as we know that the risk of relapse for bipolar disorder mood episodes in women is at least as common during pregnancy as in the non-pregnant state, and that discontinuation of medications increases the risk of relapse during p...
In a patient with well-controlled ulcerative colitis on tofacitinib for several years, would you consider switching to upadacitinib for a more favorable side effect profile?
We usually do not change away from a medication to which the patient is having a sustained response without AE. Upadacitinib is a selective Jak but same class as tofacitinib and it is unclear how much if any of a difference there is between the two in terms of AE.