Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend initiating treatment with an SGLT2 inhibitor or semaglutide first for a patient with obesity and heart failure with preserved ejection fraction?
Irrespective of body weight status, my first line of treatment for patients with HFpEF is with SGLT2 inhibitors if there are no contraindications (DELIVER trial and EMPEROR preserved trial). For patients with obesity (cardiometabolic) phenotype HFpEF, who qualify for GLP1 receptor agonists, I add on...
Are there any contraindications using nurtec in patients with headaches in the setting of recent RCVS?
I would be comfortable using Nurtec in a patient with a recent RCVS diagnosis. I am comfortable using triptans in patients with a prior stroke or MI with proper patient counseling unless they have critical/severe artery stenosis. I have had cluster headache patients who continue sumatriptan injectio...
How do you approach the management of aortic stenosis in an elderly, frail patient with multiple comorbidities who is symptomatic but considered high risk for surgical aortic valve replacement?
In an older patient with severe aortic stenosis (AS) who is not a candidate for surgery, there are 3 treatment options – TAVR, balloon aortic valvuloplasty (BAV), and medical management.In the original PARTNER trial, 358 patients with severe AS who, in the judgement of at least 2 cardiac surgeons, w...
How do you approach management of recurrent idiopathic pleuropericarditis?
The first line is colchicine and NSAIDs until the pain resolves, CRP normalizes, etc… After this, if the CRP tracks with the symptoms, fluid reaccumulation, and/or cMRI evidence of the pericarditis, I find il-1 inhibitors work very well.
Do you recommend adding Moonstone supplements for patients with recurrent calcium oxalate nephrolithiasis who are on potassium citrate but continue to have hypocitraturia?
As an inventor of Moonstone Stone Stopper, I do have a conflict of interest. Having disclosed that, I will say that it is a good way to supplement citrate. Many of my patients use BOTH K citrate and Moonstone depending on whether they have bathroom access, are traveling, or the like. Many take the t...
How soon after starting treatment would you repeat imaging in patients with Takayasu to monitor response and ensure you have the correct diagnosis?
The optimal imaging frequency and imaging modality with which to monitor disease activity in TAK are not well defined. I would highlight some general concepts that I find helpful in determining the best monitoring strategy for a given patient. 1. Imaging interval should generally be shorter in patie...
When should one consider obtaining a cardiac MRI in ischemic stroke patients?
This is a terrific question. Cardiac MRI is increasingly utilized in the diagnostic evaluation of ischemic stroke and can uncover clinically covert cardiovascular disease. The clinical utility in ischemic stroke is most in patients with concern for LV thrombus (low EF or recent anterior ST elevation...
Do oral contraceptives lower bone mineral density in women with hypothalamic amenorrhea by lowering IGF-1?
I am not aware of a well done study in this regard, but oral contraceptives containing estrogen induce growth hormone resistance and may lower IGF-1, but the beneficial effect of estrogen on bone density would almost certainly outweigh any negative effects caused by lowering the IGF-1.
How do you advise older adult patients with cognitive impairment and/or caregivers who inquire about commercial cognitive apps/games for the prevention of cognitive decline?
There is no data that suggests that participating in cognitive apps/games can help patients who already have cognitive impairment. That said, my bias is that doing something is better than doing nothing, so any cognitive challenge is better than just watching TV.There is some data that cognitive sti...
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...