Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there emerging and compelling enough evidence to maintain patients on P2Y12i monotherapy (in lieu of aspirin) following completion of DAPT?
Yes, a recent meta-analysis favors clopidogrel over aspirin for long-term therapy.Also, studies are coming out suggesting a shorter duration of DAPT.Here's one:Choi et al., PMID 36169938
What is your approach to the use of acetazolamide in patients with OSA?
I do not believe, at this time, there is very good evidence suggesting that acetazolamide should be used as primary therapy for OSA. There is a company, Desitin, that is trying to advance a different carbonic anhydrase inhibitor, sulthiame, to treat OSA, but it has not been approved to date. That be...
What is the optimal timing for Zoster vaccine administration for a patient who recently recovered from herpes zoster infection and is now planning to start B-cell depletion therapy?
This is a complicated question that must balance two competing factors. First, in general, most experts counsel waiting, approximately one year after zoster before vaccination in attempt to take advantage of endogenously boosted immunity and a low rate of recurrence within 12 months. On the other ha...
Do you recommend holding cinacalcet after kidney transplantation and monitoring PTH levels before restarting it?
Recommend to monitor calcium levels and resume cinacalcet if the patient has hypercalcemia. If the calcium level is normal, do not need to resume post-transplant. In addition, if the calcium level is 9 or below, would stop cinacalcet and monitor calcium levels.
How would you approach choosing osteoporosis treatment in a patient with a T score -3.3 in lumbar spine and no prior fracture history who has squamous cell cancer and received radiation therapy?
This is an interesting question and a not unfamiliar clinical situation. I would like to know the age of the patient of course and her general medical health including renal function as that might influence the choice of drug to be recommended. The underlying premise here (I assume) is the option of...
Would you consider teriparatide in a postmenopausal woman with normal DEXA who had a traumatic humerus fracture three months prior with surgical intervention and plain Xrays showing only partial healing?
At NYU, we have a multi-disciplinary approach to fracture non-unions and have used teriparatide in that setting usually at the request of our fracture surgeons. Those patients are not truly comparable to the patient described in your question as the non-union patients' fractures occurred significant...
How do you manage me anticoagulation in a patient with May Thurner Syndrome, who does not have history of thrombosis, and becomes pregnant?
Watch dimers, if neg, no anticoagulation; if positive, anticoagulation.
Should insulin be started early (prior to optimization of other anti-hyperglycemic medications) in patients with mild-to-moderate diabetes and hypertriglyceridemia refractory to statin and fibrates?
Not necessarily. The goal should be achieving optimal glucose control to improve triglyceride levels. This can be accomplished with non-insulin agents, such as GLP-1 agonists and others, that can have beneficial effects on triglycerides.
Should Orlistat be considered in the management of hypertriglyceridemia?
While there are no controlled trials addressing this issue, it is certainly a reasonable option which I have used in some patients with Familial Chylomicronemia Syndrome. It will help to reduce the generation of chylomicrons and therefore the subsequent risk for hypertriglyceridemic pancreatitis. Ma...
How should very low T scores (worse than -3) be interpreted in very thin patients (BMI < 18)?
It would be very helpful to know the age of the patients. Age is well documented to be independently inversely related to fracture risk for the same T score. Low BMI places less stress on the skeleton and in response the skeleton maintains lower bone mineral content i.e. bone mineral density. There ...