Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you cross-taper when switching from an SSRI to an SNRI?
It depends on which SSRI and SNRI are involved, as well as the dose of the SSRI. If switching from a low-dose SSRI, a cross-taper is not typically necessary given that both SSRIs and SNRIs increase serotonergic transmission and therefore a withdrawal effect will likely not be felt. If switching from...
How do you approach the timing of Rituximab during pregnancy in a patient with life or organ threatening autoimmune disease?
The short answer is that I give it whenever it is needed for organ or life-threatening disease. Giving it earlier in pregnancy may have less impact on the fetus/neonate. In general, we all try to avoid routine treatment with rituximab during pregnancy due to the expected placental transfer after the...
What is your approach to a patient with a low alkaline phosphatase?
This is a wonderful and increasingly relevant question as it is not uncommon for someone to have a low alkaline phosphatase and be told it is not important since alkaline phosphatase is only important if it is elevated. Causes for this abnormality include protein deficiency, Wilson’s disease, and hy...
When do you recommend acamprosate vs. naltrexone for medication-assisted therapy in alcohol use disorder?
I would suggest starting naltrexone for about a week and then transitioning to Vivitrol shots. Continue Vivitrol every four weeks as a maintenance treatment regardless of drinking levels. I would also recommend at the start of the treatment, getting some baseline labs to include a CBC, comprehensive...
In what cases do you recommend the use of gabapentin for off-label use in alcohol use disorder?
Often patients with AUD who decline first-line medication treatments, i.e., naltrexone or acamprosate, are more open to gabapentin when advised of its potential benefits for anxiety, mood, and sleep, as these are common issues that drive alcohol cravings and use. Flexible dose titrations starting wi...
What is the optimal frequency and duration of post-operative radiological surveillance following resection of a solitary fibrous tumor?
Partly depends on the subset of SFT. The classic variant is low-grade, indolent clinical behavior and can recur late (several years later) requiring (maybe less frequent) but long-term follow-up for 10 years or even beyond. The malignant SFTs have a shorter natural history and typical sarcoma follow...
Is there a role for DOAC use for patients with unprovoked PE, that have had recent sleeve gastrectomy with duodenal bypass?
Alterations in the gastrointestinal (GI) tract following bariatric surgery, as well as altered or reduced oral intake, have the potential to impair the absorption of both DOACs and VKAs in the acute setting. DOACs are absorbed in the upper GI tract, which is altered by the most common bariatric surg...
What is the role of surveillance imaging after first line therapy in patients with aggressive lymphomas?
Most relapses from complete remission in patients with diffuse large B-cell lymphoma are symptomatic. I am aware of no evidence that surveillance leads to the diagnosis of asymptomatic relapses that are more likely to respond to salvage therapy. My own concern about frequent surveillance is the adve...
Would you consider adding niacin to the lipid lowering regimen in statin-intolerant patients who cannot afford PCSK9i or bempedoic acid?
Yes, in a patient who absolutely cannot take a statin or other common alternatives such as ezetimibe, PCSK9 inhibitors, or Bempedoic acid, Niacin for ASCVD risk reduction is still a reasonable choice. While the combination of statin and niacin has been shown to be unhelpful (and possibly of greater ...
How do you identify the subset of heart failure patients who are likely to benefit from cardiac resynchronization therapy in the setting of an RBBB pattern?
There are no good criteria to delineate which patients with RBBB will benefit from traditional CRT. The best contemporary strategy is to consider CRT if a patient has an RBBB > 150 ms, an atypical morphology (suggesting an underlying delay in the LBBB or an IVCD), and Class III-IV HF symptoms. One m...