Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should patients with asymptomatic GH deficiency be treated with GH replacement therapy if they have prior known severe CAD?
Yes, GHRT should be discussed with GHD adults independently from symptoms. There is no evidence that GHRT increases the risk of CAD, and in fact, it may be beneficial due to the lowering of total and LDL cholesterol (this is a theoretical benefit, as I am not aware of any study that showed that GHRT...
Should a short trial of androgen therapy be used in patients with primary adrenal insufficiency suffering from persistent fatigue and hypoactive sexual desire despite sufficient glucocorticoid and mineralocorticoid replacement?
Considering that adrenal glands are an important source of androgens in women, this approach, especially in symptomatic patients, seems reasonable. I usually use DHEA supplements starting at 25 mg daily and then adjust the dose based on the DHEAS and testosterone levels. Most patients require 12.5 t...
Should testosterone replacement be stopped in elderly men who suffered acute stroke even when testosterone levels have been stably in the low-to-mid normal range?
Recent data are reassuring with regard to the cardiovascular safety of physiologic testosterone replacement in older men. The TRAVERSE study of 5,246 men 45 to 80 years of age who had preexisting or a high risk of cardiovascular disease and were randomly assigned to a testosterone gel or placebo sho...
Would you recommend prescribing testosterone replacement therapy to reduce osteoporosis fracture rates in men with hypogonadism?
100% yes. Especially if improved quality of life may be realized. Practitioners need to understand that TRT supersedes physiologic testosterone when it comes to quality-of-life benefits, especially INJ testosterone. That's assuming even normal testosterone to begin with. Clinical real-world benefits...
What is a reasonable duration of time for dual anti-platelet therapy in patients who have undergone placement of a covered coronary stent?
First of all, this question hasn't been studied and second, few of us have a huge experience. Based on a series of exactly 2 patients, the possibility of thrombosis is ever present. I personally continue DAPT indefinitely in this circumstance. I am reluctant to stop it entirely; for elective procedu...
How often do you monitor labs such as complete blood count, liver function panel, and urine protein in a patient with cystinuria receiving tiopronin?
I check patients newly started on tiopronin or after an increase in dosage about one month later. Assuming the lab results are normal, I do not continue to check them. I think late adverse reactions must be very rare. Stephen B Erickson, MD
How long do you continue a thiazide diuretic in a patient with nephrolithiasis and hypercalciuria who achieves normalization of urinary calcium excretion following therapy initiation?
This question needs to be viewed from many angles in considering the answer. At the first level, an effective therapy choice for stone formation should be continued as long as the patient remains a stone former, which is probably for the rest of their life. We should always remember that the desired...
Should patients of advanced maternal age (>35 years of age) undergo routine cardiovascular risk stratification with echocardiogram during pregnancy?
More and more women over 40 are becoming pregnant. Unfortunately, they experience an alarming maternal mortality rate nearly seven times higher than their counterparts under 25. In the United States, cardiovascular disease is the leading contributor to mortality. These statistics underscore the nece...
How would you approach the management of a patient with tophaceous gout who consistently has a serum uric acid under 5 on allopurinol but continues to experience gout flares?
I have a slightly different take on this question than Dr. @Dr. First Last. We don’t know from the question when allopurinol was started, what the current dose is or if the patient’s gout is tophaceous. Flares are commonly seen for several months after oral uric acid lowering therapy (ULT) is initia...
For a patient interested in home dialysis modalities, what are some key points that you discuss with them to help them make a decision on peritoneal dialysis versus home hemodialysis?
1. Dialysis access: a major difference between the 2 modalities is dialysis access. Discussion with the patient should include detailed education with photos, videos, or physical examples of a PD catheter in situ and AVF/AVG/catheter. Some patients have strong feelings regarding the issue of needle ...