Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you routinely hold OCPs to assess menopausal status, and if so, for how long?
This is a good question. Obviously, OCPs will mask a woman's menstrual cycle. In order to see if someone is truly menopausal, you will need to stop OCPs. It is unclear for how long, though. In my practice, it depends on whether the woman has pregnancy potential. If no, you can just stop the OCPs and...
How do you approach the discussion regarding loss of muscle mass with GLP-1 agonists in your non-geriatric population where the negative repercussions may not be as obvious?
We start by having the discussion PRIOR to starting the medication. We educate that this is not a GLP-1 phenomenon but a result of weight loss. We reinforce this at every dose change and at every follow-up, emphasizing protein and strength training. We use a body composition analysis scale to help p...
How do you pragmatically approach a conversation about "liver detox"/"liver cleansers" when patients bring up this topic?
It's important to keep an open mind with the use of these products, as often people will want to take them despite what you might say. Having some experience with the use of these products (or at least their ingredients) will give the patient a comfort level with freely discussing their use with you...
How do you approach a patient maintained on chronic methadone incidentally found to have a prolonged QTc?
If a patient without OUD on chronic methadone who has not previously had QTc issues, suddenly has a prolonged QTc, I look for other reversible causes such as hypokalemia, hypomagnesemia, new medications (such as recent antibiotics, Zofran), etc. From there, it's a nuanced and patient-centered risk/b...
How do you approach a patient maintained on chronic methadone incidentally found to have a prolonged QTc?
If a patient without OUD on chronic methadone who has not previously had QTc issues, suddenly has a prolonged QTc, I look for other reversible causes such as hypokalemia, hypomagnesemia, new medications (such as recent antibiotics, Zofran), etc. From there, it's a nuanced and patient-centered risk/b...
What is your treatment paradigm for rectal cancer in the setting of COVID-19?
We haven't changed our standard recommendation: short course radiation -> 3-4 months of FOLFOX. In a very timely manner, the RAPIDO ASCO abstract was released here in May. It showed that the patients who received short course radiation -> FOLFOX had improved pCR, less disease related treatment failu...
How would you manage a patient who presents with hair loss that began after they started a GLP-1 inhibitor?
If it fits with telogen effluvium, I recommend monitoring. Many patients will improve after this initial shedding and will not have long-term shedding or long-term thinning. If there is any underlying androgenetic alopecia or pattern hair loss, then starting treatment as you normally would is also r...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
There are no clinical trials or level I evidence about insomnia management in stroke patients to delineate which medications are off the bat contraindicated. Data is variable on it- some based on mouse models, based on GABAergic medications. That said, the incidence of new-onset insomnia post stroke...
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...
How do you approach the treatment of patients with Ehlers-Danlos hypermobile type with chronic muscle spasms with minimal exertion?
You accept that EDS is a genetic connective tissue disorder and not a rheumatological issue. You check hormones and vitamins to ensure they are in range: especially Mg with the cramps. Some EDS patients find working with an EDS physical therapist is beneficial: the goal being to learn how to exercis...