Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you determine whether to continue anti-dementia medications (such as cholinesterase inhibitors) for patients with dementia when enrolling in hospice?
In most cases, recommending discontinuation of anti-dementia medications when someone is eligible to enroll in hospice due to end-stage dementia is reasonable. Symptomatic benefit is less likely to be noticeable or meaningful at this stage (and benefit is small to modest even at earlier stages). Abi...
Are there other scenarios besides prior history of TIA or stroke or LV dysfunction in which systemic anticoagulation for LV non-compaction would be considered?
There is limited data in this area, but LV non-compaction by itself is not always an indication for anticoagulation. In addition to prior history of TIA, stroke or LV dysfunction, other conditions that anticoagulation should be considered include a history of atrial fibrillation or LV thrombus. The ...
In your clinical practice, do you find that patients with moderate dementia due to Alzheimer's see much benefit from increasing donepezil dosing from 10 mg/day to a higher dose such as 23 mg/day?
Personally, I do not see much benefit in increasing to 23 mg. To be fair, I do not do this very often, as our cognitive neurologists that I trained with during fellowship rarely did this, given their experience that 23 mg did not offer noticeably more benefit and often many more side effects. I have...
What are the reasons for SLE specific labs to turn negative?
I agree and appreciate the answers by Dr @Dr. First Last and Dr @Dr. First Last. My answer may be stating the obvious, but I think it is important to mention that lupus is not infrequently over-diagnosed and overtreated. Serologies are sometimes over-interpreted with low-titer antibodies labeled as ...
In adults ≥80 years with TSH 6–10 mIU/L and minimal symptoms, do you initiate levothyroxine, monitor, or avoid treatment entirely?
I tend to check free T4 in this situation. Aging is associated with some elevation in TSH value up to 10 mIU/L with normal free T4, and in those patients, levothyroxine is not needed. In some patients, I have seen it rise above 10 with normal free T4. Supplementing levothyroxine to lower serum TSH w...
In adults ≥80 years with TSH 6–10 mIU/L and minimal symptoms, do you initiate levothyroxine, monitor, or avoid treatment entirely?
I tend to check free T4 in this situation. Aging is associated with some elevation in TSH value up to 10 mIU/L with normal free T4, and in those patients, levothyroxine is not needed. In some patients, I have seen it rise above 10 with normal free T4. Supplementing levothyroxine to lower serum TSH w...
What is your approach to the management of chronic GI bleeding from AVMs in an elderly patient on DOAC for atrial fibrillation?
I would definitely strongly consider the left atrial appendage occlusion device in these patients. While usually these devices (such as Watchman) do require anticoagulation for about 45 days until the device has an endothelial layer form on it (we usually confirm with a CT scan or TEE), there are so...
Do you recommend, based on current evidence, avoiding antimotility agents in patients with non-fulminant C. difficile infection who have no evidence of ileus?
I generally avoid their use based on the notions that diarrhea may contribute to the elimination of non-invasive GI pathogens and that impairment of intestinal motility could increase the risk of complications, such as toxic megacolon.The data and recommendations have not progressed beyond the follo...
In patients with suspected RCVS, is there a role for preventative CCB if headache has resolved/now asymptomatic?
In short, the use of CCBs in RCVS is only for the prevention of thunderclap headache (TCH) recurrence. Since their purpose is to prevent TCH recurrence, they are often used when the patient is asymptomatic as well (i.e., even after the index TCH has resolved). They do have no impact on eventual clin...
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...