Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider the use of an anabolic agent to promote fracture healing?
While there are no drugs FDA that are approved to enhance fracture healing, there is considerable literature and experience using the PTH-based anabolic drugs to attempt to heal a fracture. They are sometimes used in the setting of delayed union or non-union. They have been used in elite athletes to...
Do you taper memantine after completion of 24 weeks of therapy?
Tapering is recommended when discontinuing some medications used in the management of dementia such as cholinesterase inhibitors. There are anecdotal cases of “discontinuation syndrome” after abrupt cessation of memantine in patients with dementia. However, this alone does not prove that a slow tape...
Would you use new DOAC loading dose or start with maintenance dosing for a stable patient on existing DOAC who needs to switch brand due to insurance/formulary reasons?
For some drugs, you need to do a loading dose to get the drugs to therapeutic levels. However, with DOACs, a loading dose is used at the time of VTE diagnosis and therapy initiation to jump start the anticoagulant effect when the clot burden is the highest. Thus, if you are switching from another fu...
How do you approach a patient with atrial fibrillation on apixaban who has a new cardioembolic stroke?
Assuming that the apixaban dose was 5 mg bid, I would switch to warfarin and aim for INR 2.5-3.5.
How do you approach a patient who exhibits classic bipolar symptomatology (including cycling sleep changes, behavioral changes, and mood changes) but has never responded to any form of adequate trials of mood stabilizer treatment?
I would question the diagnosis and look to better understand underlying anxiety, PTSD, or borderline personality disorder. I tend to see this in patient who have substantial trauma history. I look to treat the comorbid symptoms (insomnia, substance abuse, treating ADHD with an alpha 2 agonist, treat...
Would you stop an ACE inhibitor/ARB or instead initiate a potassium binder to manage hyperkalemia in a patient with proteinuric CKD stage 5 who is on an ACEi/ARB?
This depends on where in CKD 5 the patient is, to some extent. Would also make sure to modify diet if possible and make sure on an appropriate dose of a loop diuretic. If very close to starting dialysis or getting a txp, I might reduce dose or stop, especially if a K-binder is expensive for the pati...
For patients with spinal hardware infections, in what circumstances do you recommend 12 weeks over 6 weeks of antimicrobial therapy?
Extrapolating from PJI data, I tend to treat longer, but not always IV if there is an oral option after initial IV therapy. A big blurry line is when do oral antibiotics stop being for treatment and start being suppressive? Anyone I'm considering for long term suppressive antibiotics, really gets a ...
What advice do you offer to patients with recurrent nephrolithiasis who are on a tube feeding diet and seeking stone prevention guidance?
As always, it is important to know their stone composition, so that you tailor the invention appropriately. Regardless, I have seen many such patients with calcium oxalate stones. It is important to get detailed information about their tube feeding formula and dosing, because tube feedings can vary ...
Do you recommend combined baseline cortisol and DHEA-S testing to improve the efficiency and accuracy of adrenal insufficiency diagnosis?
Yes, especially in the absence of recent glucocorticoid exposure, which can lower DHEAS levels and make it less helpful. Han et al., PMID 39657727 recently published a comprehensive manuscript on this topic.
What do you recommend to reduce/treat skin reactions for those taking anti-CGRP monoclonal antibodies to treat migraine?
Occasionally, we see a skin reaction with the subcutaneously administered antibodies; erenumab, fremanezumab, or galcanezumab. It generally consists of slightly elevated redness at the site of the injection due to inflammation, which can be itchy. We should not interpret the itchiness as indicating ...