Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you consider using buspirone for the management of anxiety in older patients?
While buspirone has been FDA-approved for the treatment of generalized anxiety disorder (GAD) and for short-term relief of anxiety symptoms in general since the 1970s, it is not generally considered a first-line treatment, despite its low misuse potential as a non-benzodiazepine. There are no large ...
How do you make the decision to empirically treat for GCA when a patient is referred but cannot be immediately seen in clinic?
This is an important question because referrals for possible GCA are common scenarios when a rheumatologist may be asked to recommend a treatment before seeing the patient which are often challenging scenarior. The factors I typically rely on to rate the probability of GCA include: - Specific sympto...
Do you ever consider tapering off steroid-sparing agents in patients with stable non-IPF ILD?
In short, the answer is YES—I always look for ways to reduce immunosuppression exposure over time and use the lowest effective dose required to keep a patient’s inflammatory ILD in check. I often remind myself that when these patients present with a mixture of fibrotic changes (e.g., traction bronch...
How often do you rely on using the C1 inhibitor functional assay versus the quantitative level alone to diagnose HAE?
We have seen a significant increase in lab costs billed to well-insured patients for some of the more "esoteric", detailed testing associated with immune/inflammatory disorders such as HAE. The cheapest screen is a C4 level, which, if normal during an active angioedema episode, makes C1 inhibitor de...
Do you make any dose adjustments for patients with ESKD who are on apixaban and do not otherwise meet criteria for reduced dosing?
I do most of the time but it depends on the indication and patient's weight and age. For soft indications, I usually give 2.5 mg bid, but if there is a significant risk (stroke, clots, etc), I will give a full dose of 5 mg bid.
How do you determine whether to continue anti-dementia medications (such as cholinesterase inhibitors) for patients with dementia when enrolling in hospice?
In most cases, recommending discontinuation of anti-dementia medications when someone is eligible to enroll in hospice due to end-stage dementia is reasonable. Symptomatic benefit is less likely to be noticeable or meaningful at this stage (and benefit is small to modest even at earlier stages). Abi...
Do you recommend starting a statin in patients above 75 years old with diabetes but no known ASCVD?
The time to benefit (TTB) for statins in primary prevention of cardiovascular events is generally about 1.5 to 3 years. This means that adults aged 50 to 75 years typically need to take statins for at least 2.5 years to achieve a meaningful reduction in major adverse cardiovascular events (MACE), su...
Do you feel there is a role for triple-phase budesonide in the management of patients with celiac disease who refuse to follow a gluten free diet?
I do not believe it does. Budesonide is useful for acute gluten exposures and type 1 RCD but will not correct the inflammatory cascade associated with chronic gluten exposure and has significant side effects with long term use.
What continuous duration of device defined atrial fibrillation burden warrants initiation of anticoagulation if the patient qualifies by CHA2DS2-vasc score?
The topic is very controversial and there is no agreement either on the continuous duration of a single episode or the total burden required to initiate AC. Most recommendations are expert opinions. I believe that 5 minutes is the most commonly accepted cutoff, which needs to be combined with an ass...
Do you prescribe silvadene cream for patients with a sulfa allergy?
No. I will consider hydrogel wound dressings in those situations