Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you discuss the importance of ongoing lifestyle-based interventions when starting a GLP-1 agonist for medically relevant obesity (i.e., with comorbid conditions)?
I discuss the importance of ongoing lifestyle interventions by going back to the primary research for the corresponding GLPs. I point out the fact that in many of the trials, both the control group and the experimental groups would have some form of therapeutic lifestyle change (usually a mix of edu...
What typical lab tests do you send off for evaluation of neuropathy?
Not too much has changed in over a decade regarding the recommendations on how we should approach initial laboratory testing in patients presenting with a neuropathy syndrome. Specifically for cases of distal symmetric polyneuropathy, the AAN practice parameter (reaffirmed in 2022) by England, et al...
When do you start steroids for radiation pneumonitis?
Great question on a relevant clinical topic. It's very important to remember that pneumonitis is a diagnosis of exclusion. Sometimes, if the timing is right and the patient's presentation is typical, there is a tendency to move quickly to the conclusion that the symptoms are caused by pneumonitis. R...
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...
How do you approach the management of ADPKD in pregnancy, considering the need to stop tolvaptan therapy?
I generally consider transition to pregnancy with respect to both tolvaptan and ACEi along the same time frame... discuss when initiating counseling about becoming pregnant and discontinue use when patient is about to start actively trying to conceive.Additional counseling may be warranted re: blood...
When do you think physicians should seriously consider prescribing PCSK9 inhibitors for the prevention of heart attack and stroke in people with ASCVD or diabetes, based on the results of the VESALIUS-CV trial?
Although I checked 'high lipoprotein (a) as a reason to go with a PCSK9 first, I would almost never do it is practice. Statins first and then add a PCSK9 if LDL is above my goal for the patient. I might use a lower dose of the statin to get 35% lowering and then add the inhibitor if the patient was ...
What is your preferred treatment for actinic cheilitis?
PDT is effective as well as an ablative laser for long-term control. Efudex or imiquimod for multiple weeks is good for localized or milder disease. Consider getting a biopsy if you’re concerned for invasive SCC. Encourage them to use sunscreen too.
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
How do you treat depression symptoms in patients with Parkinson's disease?
The management of PD-related depression can be a little complicated, but there are several proposed algorithms out there based on varying degrees of evidence. Personally, I like this reference (Pontone and Mills, PMID 33648830) as a place to start. It makes 3 key points: Distinguishing between PD an...