Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
Peripheral edema is a common complaint and can be exacerbated by any vasodilator therapy, including hydralazine and minoxidil. My initial approach to swelling is to 1) make sure there is no proteinuria, which can be easily overlooked in a diabetic who infrequently sees doctors; 2) assess heart and l...
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...
How do you counsel patients about the potential benefits of laxatives when they are experiencing overflow diarrhea and are concerned about it getting worse with these medications?
I'll preface this by saying I rarely see this, and I will approach this answer as if this patient were in palliative care. But I think I would start with education on the mechanism of this type of diarrhea and the rationale for using laxatives to improve the situation. I would also discuss that, aft...
When stopping denosumab and transitioning to PO bisphosphonate, do you wait for 6 months after the last denosumab injection to start PO bisphosphonate?
Some background: In patients discontinuing denosumab without subsequent antiresorptive therapy, BMD rapidly reverts back to baseline with an elevation in vertebral fracture risk (with an enhanced risk of multiple vertebral fractures). Thus, sequential treatment regimens following denosumab have been...
What therapies have you found most effective for JAK-induced/associated acne (JAKcne)?
Doxy will work quickly and is pretty safe. If all goes well, you can taper the dose of the oral antibiotic and use topical agents.
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
How do you recommend mitigating the risks of using beta blocker and clonidine therapy in combination for management of hypertension?
Beta blockers vary in lipophilicity, which affects blood-brain barrier permeability. Propranolol and metoprolol readily cross the blood-brain barrier, while other beta-blockers like nebivolol do not. The CNS side effects of fatigue, depression, and insomnia are more likely to worsen if using a lipop...
What is your preferred choice of anticoagulant (VKA vs. DOAC) in patients with an LV thrombus and apical infarct?
Traditionally, warfarin is recommended. However, there has been recent evidence to suggest that DOACS are effective as well. In my practice, I have migrated to DOACS for ease of use. Many elderly patients are overwhelmed when they are discharged with 6 or 7 medications and add to that the complexity...
Do you change your pre-operative insulin dosing when patients are NPO for surgery, but also just recovering from newly resolved DKA?
For patients immediately recovered from DKA (e.g., within 72 hours), my first priority would be to delay any non-emergent surgery until the etiology of DKA has been evaluated and (if possible) addressed and the DKA has been definitively resolved with conversion off of continuous insulin and resumpti...