Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there any difference between colchicine 0.5mg vs 0.6 mg for high risk coronary artery disease?
Based on my subjective practice, no significant difference (have used both formulations). Any others have any different/similar experiences?
What patient specific factors outside of health insurance coverage do you use to decide which GLP1 R agonist or dual agonist therapy to start in patients with diabetes?
The class of drugs called GLP 1 RA continues to grow. Single agonist drugs include dulaglutide and semaglutide. There is now a “dual agonist” available for use, tirzepatide, which really is a GLP 1 RA and GIP RA. There are “triple agonists” which also bind the glucagon receptor that are close to FDA...
Which factors favor extended dual antiplatelet therapy beyond one year in ACS patients with low bleeding risk?
Selecting an optimal duration of dual antiplatelet therapy (DAPT) for a given patient (whether "extended" or "short" in comparison to one year) must be personalized, with a calculus that considers an individual's competing risks of bleeding and thrombosis as a function of time.Accordingly, without b...
How do you manage antipsychotic-induced prolactinemia?
Most patients treated with standard doses of risperidone and paliperidone will develop hyperprolactinemia, typically below 100 ng/ml. However, not all individuals with elevated prolactin levels will exhibit clinical symptoms such as erectile dysfunction, galactorrhea, or irregular/absent menstrual c...
What preventive medications do you recommend for patients with cluster headaches?
As per the 2016 AHS guidelines, here are the recommended treatments for cluster headache prevention: Level A: Suboccipital steroid injection Level B: Civamide 0.025% 100 uL nasal spray daily Level C: Verapamil 360 mg, Lithium 900 mg, and warfarin (INR goal 1.5-1.9, reserved for refractory patients),...
What is your approach for patients with recurrent nephrolithiasis who you have a strong suspicion for primary hyperoxaluria though genetic testing returns without any abnormalities?
As an adult nephrologist, most of my patients with oxalosis have enteric hyperoxaluria. I suggest you take a careful history, looking for inflammatory bowel disease, removal of small bowel or surgical rerouting of the intestines. If your patient is a child, I would explore the possibility of insuran...
What do you use for treatment-refractory anxiety where trials of antidepressants have not worked either from ability to tolerate or inadequate effect?
I find gabapentin to be very helpful for anxiety. Other agents I've found helpful include the alpha-2 agonists clonidine and guanfacine, which I've found particularly helpful for people with trauma-related anxiety and anxiety with somatic symptoms. Both are also helpful for nightmares. Regarding ga...
How do you approach the treatment of indeterminate UIP on HRCT with grossly positive MPO antibody and no other features consistent with AAV?
We see these patients in our combined ILD/Rheumatology and would treat with immunosuppressive therapy. The indeterminant UIP is likely NSIP although UIP is not an uncommon pattern seen in these patients. ILD can be the presenting manifestation in ANCA-ILD in 14-85% of ANCA vasculitis patients depend...
How often do you monitor pulmonary function tests in patients with fibrotic lung disease?
For IPF patients and those on IS meds, every 4 months, I obtain Spirometry and DLCO. I obtain six-minute walk tests every 4-6 months.
What is your approach for disease activity monitoring in patients with sarcoidosis?
Disease activity monitoring is useful in managing therapy and prognostication in sarcoidosis. Since the disease activity can vary across different organ systems, it can be a challenge. Broadly, good bio-markers of overall disease activity are lacking in this disease.ACE level lacks the sensitivity b...