Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider treating empirically for AVP deficiency in a patient who had pituitary surgery 6 months earlier and complaints of polyuria/polydipsia with dilute urine (without performing water deprivation studies)?
In the appropriate clinical setting, like this, if you have documented inappropriately diluted urine, you can treat. The chance of resolution 6 months after surgery is very low. Always instruct the patient to have a daily polyuric phase to reduce the risk of hyponatremia.
Should GLP1 R agonists be used as first line glucose lowering agents in patients with ESKD and DM2?
This is a great question, but like all clinical questions the answer will be "it depends". A provider considering adding a new drug for DM2 in a patient with CKD5/dialysis would need to know several specifics about the patient. Let's say, the patient is not on any DM2 medication. Is this an older, t...
When should metformin be stopped before surgery and when is it considered safe to resume?
Immediate release metformin can generally be continued up until the day of surgery unless there is preoperative renal compromise such that estimated GFR drops below 30 cc/min. Extended release metformin that is taken in the evening can be held on the night prior to surgery. If the patient is well wi...
Would you consider pharmacotherapy (i.e., GLP1-agonist) or behavioral/nutrition interventions alone in a patient with a remote history of a restrictive eating disorder now presenting with obesity and metabolic complications?
I would consider both pharmacotherapy and lifestyle interventions in a patient with a remote history of an eating disorder. BUT, this should be done by obesity medicine specialists who are better trained to evaluate the patient, prescribe appropriate measures, and monitor the patient carefully. Alte...
Do you still prescribe a statin for patients with diabetes on GLP-1s for cardiovascular risk reduction if their LDL is at goal?
I prescribe a statin or some other LDL-lowering medication to almost all patients with diabetes because most are not at their LDL-cholesterol goal, which is now 55 mg/dl. I also generally prescribe a low-dose statin even to patients with diabetes if they are below 55 mg/dl because patients with diab...
What is your approach to cancer patients who inquire about alternative or complementary treatments?
It depends a little bit on what specifically they want to use, and if they are truly investigating alternative medicine or complementary medicine. For people seeking full alternative medicine without any conventional treatment, I tell them that a research study showed that people who pursued the alt...
What is a reasonable approach to coronary calcification that is incidentally found on CT in a patient who does not have symptoms suggestive of angina?
This patient needs aggressive medical therapy and risk factor modifications. Statins will be the primary lipid-lowering agent but other agents as needed to get an LDL under 70. Hypertension needs to be identified and controlled. Aspirin is also a consideration depending on the extent of coronary cal...
When do you prefer bariatric surgery such as sleeve gastrectomy or gastric bypass over an initial trial of a GLP-1 receptor agonist in patients with severe obesity and painful knee or hip osteoarthritis?
I believe that this type of decision should be made by obesity specialists and not by rheumatologists. However, we can anticipate that the patient's choice is paramount: some prefer radical options such as surgery, while others cannot bear to hear about it. The decision should only be made through d...
Do you need to hold Humira (adalimumab) during radiation for breast cancer in a patient with psoriatic arthritis?
To my knowledge, there is not a lot of data on the interaction of adalimumab or other similar meds and radiation therapy. I am increasingly seeing this in my practice, however, for patients with psoriatic or rheumatoid arthritis. I discuss with patients that we have limited data on potential interac...
What is your approach to managing patients with recurrent ammonium urate kidney stones?
Pure ammonium urate stones are very unusual, and, to my knowledge, there are no studies to guide us in their treatment. Much more common are magnesium ammonium urate stones, commonly known as "struvite". These are caused by urease-producing bacteria, usually Proteus or Klebsiella. I would first chec...