Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel non-diabetic patients who wish to start metformin to reduce the risk of developing dementia?
There have been some interesting observational studies evaluating the reduction of cognitive decline in patients with type 2 DM. First, they are all in patients WITH diabetes, so not yet generalizable to patients without DM. Second, they are observational trials, which means that they cannot adjust ...
Do you typically check vitamin B6 levels in patients on Sinemet?
I check B6 levels when a patient is not responding well to carbidopa/levodopa or if I have concerns about nutritional status. I have rarely found that correcting low or high B6 levels results in clinical change in patients. If a patient were to seemingly lose efficacy from ongoing levodopa therapy, ...
How do you handle hypogammaglobulinemia detected in patients prior to maintenance rituximab infusion?
That is a good question. Adding on to Dr. @Dr. First Last's response, rituximab has been shown to cause hypogammaglobulinemia that can persist or worsen with ongoing therapy. In a study published by Barmettler and colleagues, 133 patients out of a cohort of 8633 patients had serum IgG levels checked...
How would you manage active severe psoriasis in a patient planning pregnancy, who also has psoriatic arthritis with well-controlled joint symptoms on certolizumab pegol (anti-TNF therapy)?
If the psoriasis was sufficiently limited in area that topicals were a practical solution, I'd first try to assure that the prescribed topical steroids were being used well. Poor adherence is a common issue with topical treatment. Phototherapy might be my next choice. I feel comfortable prescribing ...
Under what circumstances would you hold an ACE inhibitor or ARB prior to surgery in a patient with CKD?
I suppose if it was a high risk for hypotension or fluid shift, I may hold it. I'd rather be a bit hypertensive than under-perfused. If they are being used for reno protection, getting off them for a short period will have no influence.
Where does dronedarone fall in your list of antiarrhythmics drugs to use in terms of efficacy and patient selection in contemporary management of atrial fibrillation?
Dronedarone tends to be my last choice for treatment of AF to maintain sinus rhythm of all currently available oral antiarrhythmic meds available in the US - least effective and very expensive drug. I may use it in patients that I believe would be better served with catheter ablation- treatment with...
When home BP readings are consistently lower than office measurements, how do you decide whether to intensify, maintain, or de-escalate antihypertensive therapy?
If the home readings can be confirmed to be appropriately measured (i.e., in a hard-backed chair with arm support and checking multiple repeated readings), then I will adjust BP medications to target the average home BP of <130/80 (going lower toward 120/80, if tolerated). However, I have had patien...
What is your medication of choice when considering outpatient alcohol withdrawal management (diazepam vs chlordiazepoxide vs lorazepam)?
While benzodiazepines such as chlordiazepoxide, diazepam, and lorazepam remain the mainstay of treatment for acute alcohol withdrawal syndrome (AWS), their use in the outpatient setting is generally inappropriate for patients with Alcohol Use Disorder (AUD)—except in narrowly defined, low-risk scena...
What is your medication of choice when considering outpatient alcohol withdrawal management (diazepam vs chlordiazepoxide vs lorazepam)?
While benzodiazepines such as chlordiazepoxide, diazepam, and lorazepam remain the mainstay of treatment for acute alcohol withdrawal syndrome (AWS), their use in the outpatient setting is generally inappropriate for patients with Alcohol Use Disorder (AUD)—except in narrowly defined, low-risk scena...
Do all patients initiating omalizumab need to have it administered in a healthcare setting?
In the trials, all cases of anaphylaxis were on first administration--suggesting it is not intrinsic to drug and is more likely because you are giving it to a group of people who may be more susceptible to anaphylaxis in general. FDA has cleared at home use, so my general approach in a patient witho...