Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider adding an SGLT2i for a patient with proteinuric kidney disease who is already on maximal dose ACEi/ARB and has a UACR < 300 mg/g?
I not only would consider it, I've done it on many occasions. There's nothing magical about UACR <300 that eliminates the risk of CKD progression. The risk decreases but it's not an inflexion point. The lower the albuminuria, the lower the risk of progression, which has been well demonstrated in IgA...
Can sotalol initiation for atrial fibrillation be performed safely outpatient, and if so, what would be a reasonable protocol for implementing this?
In my opinion, sotalol (and Tikosyn) should never be initiated as an outpatient. We have all seen cases of torsades at some point in our careers related to sotalol initiation and QT prolongation, even when resuming a dose that was previously tolerated. There is a nice review article published in JAC...
Do you stop TNF inhibitors during the third trimester of pregnancy?
TNF inhibitor use in pregnancy is a common topic I review with patients. I make sure I include family members in my medication safety talks as well as provide tangible information, because unfortunately in the US there is a harmful stereotype that medications taken in pregnancy are bad and pregnant ...
Do you typically adjust pump settings for patients with diabetes who are on automated insulin pumps and fasting all day for religious reasons such as Ramadan?
I would decrease basal rate to 80% if well controlled but if not, continue the same.
What is your approach to managing ILD associated with inflammatory bowel disease?
We must first convince ourselves that the "ILD" relates to the underlying IBD. Patients may be on an immunomodulating regimen that increases the risk of opportunistic infections. The regimen itself may cause diffuse pneumonitis. Environmental/occupational exposures may also play a role. Armed with c...
How would you manage a patient taking a GLP-1 agonist for weight loss who continues to have symptoms (i.e., nausea, vomiting) related to reduced GI motility despite dose adjustments?
Anecdotally, I’ve had good success using prucalopride at twice-daily dosing (0.5 mg BID or 1 mg BID) in select patients. In my experience, tirzepatide tends to be better tolerated than semaglutide from a gastrointestinal perspective.
Given recent trials for the management of atrial fibrillation with an early ablation strategy (for example, EAST-AFNET 4, EARLY-AF, PROGRESSIVE-AF, STOP-AF), what is your approach to determining the appropriate timing for ablation in patients with atrial fibrillation?
I agree with Dr. @Dr. First Last. I also usually start with an antiarrhythmic drug and then offer ablation if the drug is not tolerated or is ineffectual. This is a shared decision-making process - some patients want nothing to do with drugs and prefer ablation and others want to try multiple drugs ...
What is your approach to managing concurrent severe SIADH and large-volume malignant ascites when aggressive volume removal appears to exacerbate both symptoms and hyponatremia?
A challenging situation. I would approach it in a few steps: Ensure adequate solute intake since solute load determines free water clearance in SIADH. Loss of solute from repeated large-volume paracenteses can add a component of hypovolemic hyponatremia, and people with cancer and large ascites tend...
Do you ever stop tobramycin prophylaxis in a patient with chronic bronchiectasis previously colonized with pseudomonas?
Yes, I will often stop tobramycin if there are issues with tolerance, antibiotic resistance, or treatment fatigue. Further, in more mild bronchiectasis (cylindrical vs. varicoid or cystic morphologies), sputum bacterial cultures will negatively convert on chronic cycled inhaled tobramycin, and this ...
What is your approach to a child with toe walking with a reassuring exam but a family history of difficulty walking?
For all children with toe walking, it is critical to perform a full neurological examination to look for CNS (i.e., CP/HIE or HSP) or neuromuscular (i.e., CMT, myopathy) issues. We also do NCV and EMG (the latter if indicated) even if the examination is normal and have found early CMT in a few of th...