Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When evaluating an older adult patient for cognitive concerns, what is your process for deciding whether or not to refer them for neuropsychological testing?
When I'm deciding whether to pursue neuropsychological testing, this can come down to 2 questions: Will the results change management and/or prognosis? Can the person do the testing? 1) Will the results change management and/or prognosis?Many different aspects can inform this question. F.e., Is this...
How do you treat disruptive mood dysregulation disorder?
DMDD is quite an enigma. The whole concept of irritability, which transcends many diagnoses, is also interesting. DMDD was meant to avoid overdiagnosis of moody disruptive behavior as bipolar. Since many of those kids are not suffering from bipolar disorder, I thought it was a great move. Unfortunat...
How do you discuss the importance of ongoing lifestyle-based interventions when starting a GLP-1 agonist for medically relevant obesity (i.e., with comorbid conditions)?
I discuss the importance of ongoing lifestyle interventions by going back to the primary research for the corresponding GLPs. I point out the fact that in many of the trials, both the control group and the experimental groups would have some form of therapeutic lifestyle change (usually a mix of edu...
What typical lab tests do you send off for evaluation of neuropathy?
Not too much has changed in over a decade regarding the recommendations on how we should approach initial laboratory testing in patients presenting with a neuropathy syndrome. Specifically for cases of distal symmetric polyneuropathy, the AAN practice parameter (reaffirmed in 2022) by England, et al...
How do you choose among SSRIs and dosing strategies for the management of behavioral and psychological symptoms of dementia?
The best supported SSRI for BPSD generally is citalopram. Much of this came out of the CitAD trials [1]. This primarily showed citalopram may be useful for hyperactive behaviors, irritation, but also for depression and anxiety [1, 2]. The effect and response to citalopram, though, may be affected by...
When do you start steroids for radiation pneumonitis?
Great question on a relevant clinical topic. It's very important to remember that pneumonitis is a diagnosis of exclusion. Sometimes, if the timing is right and the patient's presentation is typical, there is a tendency to move quickly to the conclusion that the symptoms are caused by pneumonitis. R...
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...
At what point would you consider stopping antidepressant treatment of late life depression after remission?
My first step here would be to answer some clarifying questions: What is the patient's current prognosis? (If the patient has a limited life expectancy- weeks to small order months- then I would certainly consider deprescribing with more ease.) Are there any foreseeable anticipated triggers for depr...
Which patients with mild cognitive impairment do you consider referring for amyloid-targeted therapy?
This is an important question, as clearly, not everyone with MCI is appropriate or interested in Amyloid-Targeted Therapy. In general, I would say that the TRAILBLAZER-ALZ 2 trial did not change my approach to patient selection much, but it did provide more evidence that this class of drugs has a pl...
Which patients with mild cognitive impairment do you consider referring for amyloid-targeted therapy?
This is an important question, as clearly, not everyone with MCI is appropriate or interested in Amyloid-Targeted Therapy. In general, I would say that the TRAILBLAZER-ALZ 2 trial did not change my approach to patient selection much, but it did provide more evidence that this class of drugs has a pl...