Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you transition to a topical retinoid after a patient completes a course of isotretinoin?
Yes. I give them the RX and tell them to start 4-6 weeks after completing the isotret course. Most of my acne patients are adult females (my niche), so using the retinoid is integral for anti-aging. I also find it helpful with any leftover scarring or pigmentation. Choice of retinoids depends on ski...
When and how should we be stopping GLP-1 Receptor Agonist/Dual Agonist therapy?
I usually continue for 3-4 years, the tapering down slowly over 1 year period, buy then the set point for energy expenditure and appetite likely is changed.
Do you get volumetric MRI in all patients with cognitive difficulties?
Yes, I find MRI very useful in assessing patterns of atrophy, as well as the degree of vascular changes in the brain. It can help confirm suspected diagnoses such as frontotemporal dementia or Alzheimer's disease.
When would you consider proceeding with antiarrhythmic drug load concurrently with DCCV as opposed to DCCV alone in patients with new-onset atrial fibrillation?
There is no expert consensus. If we are dealing with a first episode of AF, and we know that the arrhythmia has a short duration and the anatomic substrate is not severe, I would proceed with cardioversion alone. After all, we learned from AFFIRM that many patients randomized to "rate control" after...
How would you approach management of a patient with longstanding history of SLE, but having active psoriasis?
In addition to above, I would consider deucravicitinib. It has PASI75 scores that are in the 60s, and is in trials for SLE. Its phase 2 trials seemed promising. Other PO JAK inhibitors should be efficacious but may carry worse side effect profile. I have also employed PDE4 inhibitors such as po apre...
Are there instances when you recommend against a kidney biopsy in a patient with a single kidney who otherwise has indications for a biopsy, consents, and has no medical contraindications for the procedure?
I don't think so. These days the risks of having to do nephrectomy after kidney biopsy is very small and having a single kidney is a weak argument for not doing kidney biopsies. In my practice, a patient with a single kidney would get biopsied by interventional radiology to minimize the risk as much...
Do you prefer sodium bicarbonate or sodium citrate in your chronic kidney disease patients with metabolic acidosis?
I have always used sodium bicarbonate in this scenario. The easiest/cheapest way to prescribe it is to advise patients to use Arm & Hammer baking soda, which is essentially sodium bicarbonate. I gm of sodium bicarbonate provide 11.9 mEq of bicarbonate; therefore one half of a teaspoon (about 2.5 gm)...
Do you offer home administration of ESAs for your patients with anemia of chronic kidney disease?
Yes, it the patient's prescription drug plan allows it. Traditional Medicare does not allow home administration of ESAs since they are covered under part B rather than part D. However, many Medicare Advantage and commercial insurers do allow for home administration of ESAs, so I offer that option to...
How do you approach consults regarding clearance of patients with chronic kidney disease for surgery?
I never provide "clearance" for surgeries. I comment whether kidney disease is stable and whether there are any contraindications to surgery, medications, etc. based on the kidney disease.
How would you manage a patient with symptomatic Paget’s disease and osteoporosis who developed new fragility fractures while on Fosamax?
This is a complicated patient, and symptomatic Paget's needs more information. But given one wants to treat the Paget's and there are fragility fractures I would give an injection of Zoledronic Acid (mostly for the Paget's) and if needed, start Romosozumab for the fragility fractures. However, I wou...