Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you avoid the use of GLP-1 R agonist therapy for treatment of obesity in patients with known gastroparesis?
Short answer: yes. Gastroparesis is a well-known side effect of GLP-1 RA therapy. It is dose-dependent, so some patients may tolerate smaller doses but not the highest ones. A recent head-to-head trial of semaglutide vs tirzepatide in obesity (Aronne et al., PMID 40353578) found similar rates of gas...
How do you differentiate cognitive impairment from normal age-related cognitive decline?
Dr. @Dr. First Last's answer is right on target. I have a couple of additional tips when taking a history. First: normal cognitive decline would include certain features and not others. Normal aging typically leads to slower processing, more effort with multitasking and learning something new, and m...
What are the current clinical practices for TEE to guide cardioversion and anticoagulation duration post-cardioversion for Afib/flutter in patients following left atrial appendage closure?
Right now, there is not a great deal of data to guide us to answer this question. In general, the safest thing from a stroke prevention standpoint would be to adhere to the same guidelines that we would for patients without left atrial appendage occlusion devices. However, of course, most of these p...
Is it reasonable to consider the use of DOACs for LV thrombus management instead of coumadin?
I have no qualms whatsoever at using a DOAC instead of Vitamin K antagonist in this situation, provided that the patient doesn't have a mechanical valve. Endothelium is endothelium, so mechanistically I don't see much of a difference between using a DOAC to prevent/treat an LAA thrombus versus an LV...
How do you decide when to initiate or restart diuretics in a cirrhotic patient with ascites if they are receiving a therapeutic paracentesis?
This question has two parts, one with a straightforward answer, the other with a much more nuanced answer, if I understand it correctly. Any patient receiving a therapeutic paracentesis should start/restart diuretics afterwards. Per the 2021 AASLD guidelines, one of the statements reads “LVP is the ...
How do you counsel patients who are concerned that discontinuation of certain chronic medications may actually perpetuate suffering at the end of life?
Great question, and it’s very nuanced. I’ll share how I typically approach this based on my experience. In the end-of-life care setting, when I review a medication list, I go through every single one and ask: “What is the purpose of this medication in this particular case?” For example, anticoagul...
How do you counsel patients who are concerned that discontinuation of certain chronic medications may actually perpetuate suffering at the end of life?
Great question, and it’s very nuanced. I’ll share how I typically approach this based on my experience. In the end-of-life care setting, when I review a medication list, I go through every single one and ask: “What is the purpose of this medication in this particular case?” For example, anticoagul...
How do you titrate opioids for pain and breathlessness in patients with a DNR/DNI code status, but who otherwise still wish to pursue life-prolonging treatments?
Carefully! But let's be very clear about this situation: the DNR/DNI status shouldn't really affect your management if the patient wants full treatment otherwise. In fact, even if someone opts for a hospice care plan and does not want full treatment nor resuscitation, we can still have the same gene...
Do you prescribe a low-dose tricyclic antidepressant as a gut-brain neuromodulator for a patient with IBS that has not responded to dietary modification and first-line pharmacotherapy?
Yes, I do. In fact, I consider a tricyclic like imipramine (highest GI effects) to be first-line pharmacotherapy.
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...