Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you routinely prescribe vitamin D to reduce the risk of fall-related fractures in elderly patients regardless of their serum levels?
Right now, the evidence would NOT support daily vitamin D in older adults who are not deficient just for the purposes of fall prevention. Kahwati et al., PMID 33847712However, lots get missed on fall prevention - so be sure to review all risk factors and make a personalized plan (STEADI resources ar...
When do you send for genetic testing (e.g., SPINK1, PRSS1, CFTR) in a patient with recurrent or chronic pancreatitis without an obvious etiology and how does it impact your management?
I offer and discuss getting genetic testing in patients with idiopathic recurrent acute pancreatitis or chronic pancreatitis, more frequently in younger patients. Impact of testing can help identify undiagnosed CFTR patients, for whom further CF evaluation and management including options to try new...
In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?
When someone with ILD has an isolated biomarker without other clinical features associated with that biomarker, I have to ask myself these questions: first, is the biomarker simply a false positive because I have tested a plethora of biomarkers and second, is ILD the initial or only manifestation as...
How do you manage patients with chronic migraine as well as medication overuse headaches?
I agree with Dr. @Dr. First Last about the treatment for chronic migraine and MOH for patients on opiates and/or barbiturates. If they are taking frequent opiates, I prefer to have a pain management doctor detoxify them. In the past, I slowly decreased their medication while giving them long-acting ...
How do you manage patients with chronic migraine as well as medication overuse headaches?
I agree with Dr. @Dr. First Last about the treatment for chronic migraine and MOH for patients on opiates and/or barbiturates. If they are taking frequent opiates, I prefer to have a pain management doctor detoxify them. In the past, I slowly decreased their medication while giving them long-acting ...
When do you select cholinesterase inhibitors vs NMDA-antagonist medications in patients with moderate Alzheimer’s dementia?
Cholinesterase inhibitors should be given to all patients (unless there is a contraindication) with Alzheimer's dementia since this class slows cognitive and functional decline as well as reduces all-cause mortality. Memantine, an NMDA receptor antagonist, is only FDA-approved for moderate to severe...
Do you use DOAC in patients with mild or moderate rheumatic mitral stenosis?
Although using DOACs in this population may be safe, these patients were excluded from the large DOAC trials. In addition, MS progresses, so what may be moderate disease today will progress rapidly in some patients. Thus, if anticoagulation is necessary and a VKA is a major issue for the patient, a ...
Under what circumstances do you recommend targeting a systolic blood pressure of less than 120 mmHg in a patient with CKD?
I am going to deviate a bit from the KDIGO recommendations here, and will try to document my reasons. The SPRINT trial, which was the largest BP target trial for individuals with CKD, did not enroll individuals with an eGFR < 20. The automated office BP measurement used in SPRINT is still not standa...
At what eGFR do you typically refer for vein mapping for a patient with advanced CKD who prefers hemodialysis when indicated?
This is a big "it depends". Depends on trajectory of GFR loss, likelihood of preemptive transplant, my best clinical guess of the likelihood of successful fistula vs need for graft, etc. But in general, if it seems like HD start would be within 4-6 months.
What are your preferred second-line medications for trigeminal neuralgia?
My first line is oxcarbazepine or carbamazepine. The second line is gabapentin. Then, in no particular order, baclofen and lamotrigine. Other options to try: pimozide, tizanidine, phenytoin, valproic acid. If 1 agent does not provide good control, I refer to a surgeon as we try a 2nd agent.