Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should we be more cautious with the use of GLP 1 R agonist therapy in patients with Type 1 diabetes mellitus and obesity given the increased risk of cardiovascular disease with high body weight variability?
There doesn't seem to be any evidence that GLP-1 RA would increase the risk of CV disease. Biologically, the benefits that have been shown in patients without Diabetes (the SELECT trial) should still be applicable for patients with Diabetes Type 1.The trials that didn't show much efficacy in glucose...
When managing patients with suspected MASLD, what specific criteria or findings would prompt you to refer them to hepatology?
In patients with suspected MASLD, I consider referral to hepatology when there is evidence of fibrosis by elastography or if I don't see improvements in related parameters with weight loss and/or medical therapies (GLP1-related meds, SGLT2i, TZDs).
How do you approach workup and management of hyperhidrosis?
Oral anticholinergics
Would you consider the use of low-dose naltrexone in patients with fibromyalgia and/or type 2 lupus symptoms?
Yes, I think it is worth trying low-dose naltrexone in fibromyalgia - seems safe and may be effective.
What is your approach to initiation of mirtazapine for appetite stimulation and depression in older adults, both in terms of starting dose and titration?
I consider initiation of mirtazapine for older adults who could benefit from at least two of the three potential effects of mirtazapine - improvement of mood, appetite, and/or sleep. I always start at a low dose of 7.5 mg nightly, potentially uptitrating to 15 mg nightly after a week or two if the m...
Can patients "age out" of screening colonoscopies if, on their last colonoscopy prior to turning 76, they had tubular adenomas?
How long ago was the last colonoscopy? How many adenomas? How old is the patient now? State of health and expected longevity? What does the patient want? Frankly, at this point, I think I’d probably be content with an annual FIT.
Can patients "age out" of screening colonoscopies if, on their last colonoscopy prior to turning 76, they had tubular adenomas?
How long ago was the last colonoscopy? How many adenomas? How old is the patient now? State of health and expected longevity? What does the patient want? Frankly, at this point, I think I’d probably be content with an annual FIT.
What is your preferred method for subclinical CAD screening prior to initiation of class IC antiarrhythmic drugs for atrial fibrillation?
Flecainide and propafenone are the IC agents in use for atrial fibrillation. Encainide and moricizine were predominantly used for ventricular arrhythmias and encainide was pulled a long time ago due to proarrhythmia concerns and I believe Ethmozine stopped being marked many years ago.The CAST trial ...
How do you counsel patients who express concerns about receiving multiple vaccinations at once versus spacing them out over time?
The evidence shows it’s fine to give several vaccinations at once, but if you prefer to space them out, that’s fine as well. Just don’t forget to get all the recommended ones.
Is addition of SLIT likely to provide additional benefit for isolated dust mite allergy that is not completely treated with SCIT?
I offer both and have patient decide.