Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients with CKD who are on a PPI given a prior observational study showing an association between PPI use and incident CKD?
I am a little conflicted about this topic and have changed my practice in the last 4-5 years.There are multiple observational studies that suggest an association between PPI and CKD but residual confounding remains a concern in these studies. A nice commentary on this topic was published last year i...
Do you recommend obtaining one or two 24-hour urine stone risk profile(s) when evaluating patients with nephrolithiasis?
I would say that two is optimal, and ideally 1 of these on a work day and 1 on a non-work day. However, the practice setting and clinical situation with the given patient might also determine how hard this is to do in practice, and if you would do this in every patient or set things up differently. ...
When (if ever) do you recommend taping a patient off of buprenorphine after sustained remission?
I rarely recommend tapering off buprenorphine after sustained remission for opioid use disorder (OUD) because typically, buprenorphine is well-tolerated, risks are minimal, tapering can be challenging, and the risk of overdose after tapering off MOUD is high.Instances when I would consider a taper a...
When (if ever) do you recommend taping a patient off of buprenorphine after sustained remission?
I rarely recommend tapering off buprenorphine after sustained remission for opioid use disorder (OUD) because typically, buprenorphine is well-tolerated, risks are minimal, tapering can be challenging, and the risk of overdose after tapering off MOUD is high.Instances when I would consider a taper a...
What is your preferred, first-line class of anti-anginals for MINOCA with proven epicardial coronary vasospasm?
We typically start with long-acting nitrates such as isosorbide mono or dinitrate, but often patients will have adverse effects to nitrates that make long-term use challenging. We have had good results with non-dihydropyridine calcium channel blockers, particularly diltiazem, both as short and long-...
Do you routinely check vitamin K levels in post-bariatric surgery patients?
Vitamin K levels are not checked routinely in post-bariatric surgery patients. Deficiency of this vitamin is very uncommon in patients who have undergone a sleeve gastrectomy and even with Roux-en-Y gastric bypass. There is more potential for deficiency in patients who have had biliopancreatic diver...
What is your approach to deprescribing gabapentinoids so as to prevent withdrawal effects?
Prescriptions for gabapentinoids are increasingly common, particularly for off-label indications such as neuropathic pain (1). There is relatively limited evidence to guide deprescribing strategies for gabapentinoids, as demonstrated in a 2023 scoping review (2). Abrupt discontinuation of gabapentin...
What is your approach to deprescribing gabapentinoids so as to prevent withdrawal effects?
Prescriptions for gabapentinoids are increasingly common, particularly for off-label indications such as neuropathic pain (1). There is relatively limited evidence to guide deprescribing strategies for gabapentinoids, as demonstrated in a 2023 scoping review (2). Abrupt discontinuation of gabapentin...
How do you approach the work up for patients with fibromyalgia and hypermobility?
I agree the folks that are hypermobile are very challenging and it can be difficult to feel confident in hypermobile EDS diagnosis, particularly with sort of nebulous criteria. I have also found that medical genetics referrals where I practice have over a year-long waitlist, and as there is no genet...
How to you approach the risk/benefit discussion for hormone replacement therapy in perimenopausal women with significant vasomotor symptoms and borderline ASCVD risk?
Thank you for this question. It is a conversation of a bit complex nature to be had with the patient. Generally, I follow the steps of [1] educating the patient on the data on the use of HRT in setting of ASCVD in that HRT is indicated for treating moderate to severe perimenopausal symptoms up to 5 ...