Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach the use of stimulants in patients with ADHD with previous or current substance use disorders?
I agree with Dr. @Dr. First Last about the use of non stimulants as an important intervention with these patients with the added caveat that Wellbutrin XL is highly abused by crushing it up and snorting it. Even this strategy has its limitations in addressing the issue of ADHD and Substance Use Diso...
How do you engage and approach a patient presenting with psychotic symptoms who has demonstrated a pattern of malingering and also has polysubstance use disorder?
This is a nice general summary of some basics, non-judgemental, supportive approach, quiet/low stimulation environment: Mental Health First Aid Guidelines. With regards to malingering and how to approach it, try to determine the real want/need (housing or food insecurity?) and if it is something tha...
How do you manage patients with alcohol use disorder who express interest in moderation rather than full abstinence?
In the past, I would try to engage these patients in complete recovery—AA, etc. Today, having read the literature on harm reduction and perhaps being more experienced and tolerant with age, I engage the patient in healthcare activities like exercise, sleep, and diet, and discuss recovery from alcoho...
How do you approach weaning patients off of buprenorphine?
I have found using injectable extended release buprenorphine (XR-BUP) as a good way to help patients taper off SL buprenorphine in a means much more tolerable than trying to taper SL buprenorphine. We published a case series on this approach (Ritvo et al., PMID 32925232) and subsequently another cas...
Have you incorporated National Acupuncture Detoxification Association (NADA) ear acupuncture into the treatment of substance use disorders?
No, not necessarily. Perhaps on a case-by-case basis, and with patient request, this option is considered. Don’t have evidence-based data to support its use.
What factors influence your decision to start salt tablets, urea, or a vaptan first in the management of a patient diagnosed with SIADH?
In patients with SIADH, free water intake has to be less than the urinary electrolyte-free water clearance in order for the serum sodium level to increase, assuming no significant extra-renal fluid losses. Therefore, if urinary electrolyte-free water clearance is very low, then free fluid restrictio...
What is your approach to a positive PPD or IGRA in a patient with well-controlled HIV without significant TB risk factors?
I treat all HIV patients with positive screening tests. I consider HIV itself, regardless of CD4 count, to be the highest risk for reactivation disease. I believe there is data showing this risk to be higher even than organ transplant or cancer treatment patients. The problem, of course, is navigati...
During treatment of severe osteoporosis with PTH analogs (abaloparatide), would a rise in alkaline phosphatase level >200 (in the setting of normal GGT) warrant discontinuation of medication?
During treatment with PTH analogs, it is not recommended to monitor the alkaline phosphatase but only Vitamin D and calcium every three months. The alkaline phosphatase, of course, increases with PTH analog therapy, but there is no upper limit, and the concerns about osteosarcoma have been removed f...
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 approach the management of a patient with symptomatic iron deficiency anemia who is intolerant of iron?
Oral iron will not work. I would bet my last dollar there was no anaphylaxis but rather an imprudently treated minor infusion reaction which is the cause of ostensible “anaphylaxis” over 99% of the time. You can’t verify that it was real because I can assure you: It was not. They did not do a trypt...