Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you use febuxostat for an African-American patient with gout and previous cardiovascular events (stroke, MI) who tested positive for HLA-B*5801?
Well, I would certainly avoid using allopurinol. The initial CARES trial raised concerns about the safety of febuxostat, using a median dose of 40 mg. The subsequent study FAST did not show any signals of CV disease using a median dose of 80 mg. The internal validity of the study was greater in the ...
Is there a role for use of GLP1 R agonist or dual agonist therapy for management of post bariatric hypoglycemia and dumping syndrome?
There is little systematically collected information in this area on which to base judgments. A case series of 5 post-bariatric surgical patients treated empirically with liraglutide described reduction of hypoglycemic events based on patient history. In an experimental study comparing several treat...
What is your approach to a newly diagnosed LBBB in individuals >70 years old who are free of any signs or symptoms of heart disease and without other significant ASCVD risk factors besides age?
The presence of BBB; whether IVCD or RBBB or LBBB, signifies infranodal conduction delay from a myopathy. That myopathy may be hypertensive (LVH) or ischemic (LAD disease) or something less common (inflammatory etc). The ideal test would evaluate anterior septal LV thickness and vascular flow; it’s ...
What is your approach to duration of fidaxomicin in a patient receiving treatment for first C difficile infection while also receiving concurrent antibiotics for an infection?
Yes, I would extend the duration of Fidaxomicin for at least 7 days past the completion of antibiotics. Additionally, I would consider resuming Fidaxomicin if a patient needs additional antibiotics within 2 weeks of having completed C diff treatment.
What is your approach to duration of fidaxomicin in a patient receiving treatment for first C difficile infection while also receiving concurrent antibiotics for an infection?
Yes, I would extend the duration of Fidaxomicin for at least 7 days past the completion of antibiotics. Additionally, I would consider resuming Fidaxomicin if a patient needs additional antibiotics within 2 weeks of having completed C diff treatment.
How do you manage orthostatic hypotension in patients with Parkinsonian syndromes?
Don’t forget to check for adjunctive medications including urinary alpha antagonists which can cause orthostatic hypotension. If possible, reduce doses of cardiac medications. If this is not possible, then consider small frequent meals, exercise, especially the lower extremity elevating the head of ...
Do you account for the effect of coffee on platelet aggregation studies?
Although recommendations from the International Society of Thrombosis and Haemostasis (ISTH) [1] suggest that individuals should avoid caffeine for at least 2 hours before blood is drawn for light transmission platelet aggregation studies, (and be fasting, be rested for 30 minutes, and avoid smoking...
How long after initiating mycophenolate do you wait before tapering prednisone off in patients with myositis-associated ILD?
Taper Pred after 6 weeks MMF tapering to prednisone 20 mg/day and hold this dose for 6-8 weeks monitoring for relapses. If no relapse, taper to Prednisone 10 mg/day.
Would it be reasonable to begin considering GLP1 RAs or finerenone for patients with heart failure with recovered LVEF in light of recent trials such as SELECT and FINEARTS-HF showing some success in HFpEF and HFmrEF populations?
I reject the premise of the question. Patients with HFrEF who improve on medical therapy do not become HFpEF. The pathophysiology of these diseases are entirely distinct and it speaks to the limitation of EF as a categorical variable. HFrEF patients have cardiomyopathy that manifests over time as di...
Is a target TSH closer to the mid normal range justified in older individuals (age 70 or above) without any known cardiac ischemia or dysrhythmia or osteoporosis?
There are observational data showing decreased mortality rates and improved measures of well-being in elderly persons with TSH levels that are above the traditional reference range for the general population. Therefore, having a target TSH range of about 7 is more appropriate for elderly persons. Th...