Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For patients who have undergone ablation for atrial fibrillation with elevated bleeding risk, what is your risk/benefit approach when deciding to continue oral anticoagulation long-term?
I would generally determine the continuation of anticoagulation based on the patient's ChADSVASC score rather than the perceived success of ablation as many will have a burden of subclinical PAF despite ablation. So, if they are at high risk for stroke/systemic embolism, based on ChADSVASC, I would ...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
What measures should we take regarding routine follow-up visits for well patients in surveillance during the coronavirus pandemic?
3-6 months.
What is your typical menopausal hormone therapy (MHT) regimen of choice in perimenopausal women with significant vasomotor symptoms and heavy (but increasingly irregular) menstruation?
The first question for a perimenopausal woman seeking treatment of her vasomotor symptoms (VMS) is whether or not she is at risk for unwanted pregnancy (all women having sex with men up to the age of 55 are at risk of pregnancy). If she is at risk for pregnancy, it is advised to use an MHT regimen t...
Would you stop current immunosuppressive therapy or delay starting immunosuppressive therapy in a patient with aplastic anemia who has been infected with COVID-19?
Not much is known yet about this specific situation—but our growing experience here in New York City suggests it may be safe. We have had several post-BMT patients who were on immune suppression for GVHD become COVID positive who have not had significant problems. Also, we have now treated 8-10 pat...
In middle-aged adults with TSH 5–10 mIU/L and no symptoms, would you start levothyroxine or monitor, and does your threshold change with cardiovascular risk factors?
In a middle-aged patient with a TSH between 5-10 and no symptoms, I would initially monitor their thyroid levels. I would consider checking a TPO antibody titer; if positive, the rate of transition to overt hypothyroidism is greater. I would also screen for other medical issues that could be impacte...
What is the role for checking uric acid levels in evaluation of SIADH in hospitalized older adults?
Uric acid is typically not a first-line test for evaluation of hyponatremia. It's usually used when trying to differentiate between hypovolemic states (not SIADH by definition) and euvolemic states (including SIADH). The utility stems from how uric acid is handled in the nephron, i.e., it's reabsorb...
How long would you recommend that a patient continues guselkumab prior to deciding that the therapy is not effective?
Many trials have a placebo-controlled period of 12-24 weeks. Thereafter, all patients receive active treatment. Even if the original treatment allocation remains unknown to the patient and doctor, they know that from that moment on, everyone receives active treatment. This will have an influence on ...
Is there anything you use for patients with anticipatory nausea who has failed Ativan and Zyprexa?
I know of no data, but I would consider hypnosis, mediation and mindfulness, cognitive behavioral therapy, acupuncture, and medical marijuana as possible options for anticipatory nausea refractory to lorezapam and Zyprexa. Hypnosis, mindfulness, and cognitive behavioral therapy are in a sense are re...