Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What are your preferred non-benzodiazepine therapies for the hyperactive/agitated phase of methamphetamine withdrawal, both in the hospital and in the office?
In our outpatient substance use disorder practice, we tend to use lisdexamphetamine (Vyvanse) at fairly high doses off-label for patients with meth withdrawal. We establish a buddy system preferably with someone who lives with them, provide Suicide hotline phone number, describe reasons to transport...
What strategies do you recommend for discussing the use of OCP in women with a history of migraines with or without aura?
In light of the recent publication from 2025 publication by Ihara et al. in Cephalagia, modern low-dose combined hormonal contraceptives (CHCs) do not appear to add vascular risk in otherwise healthy young women with migraine. Migraine with aura remains an important marker of vascular risk regardles...
Do you routinely treat patients with neurosyphilis with IM penicillin for 1-3 weeks after completing a full treatment course of IV penicillin?
The same question was asked almost exactly two years ago. Repeating the same reply with minor edits: This has been a topic of a debate among syphilis experts for decades. There are no data at all on whether there is benefit (e.g. in preventing later relapse) in adding low-dose but long-acting penici...
What studies do you find helpful to determine if an axial spondyloarthritis patient presenting late in the disease course with significant irreversible joint damage may benefit from immunosuppression?
I think this is a very clinically relevant question. While I do not know of any study that specifically examines this question, studies suggest that tumor necrosis factor inhibitors may inhibit long-term radiographic progression and improve functional status. Long-term extension of secukinumab trial...
How do you approach the concept of spondyloarthritis disease activity "burning out" and no longer requiring immunosuppression?
This is a difficult question to discuss academically, as we will have to accept a definition for “burning out,” which may or may not be synonymous with remission or a state that will support drug-free remission. That being stated, the possibility of spondyloarthritis going into remission (no “inflam...
Do you use buprenorphine in patients with chronic pain and prior history of opioid use disorder?
Absolutely. Buprenorphine is an excellent, evidence-based medication for patients with opioid use disorder, opioid use disorder with chronic pain, and chronic pain alone. The evidence in support of buprenorphine for pain has continued to accumulate over the past 10 years. At this point, I would neve...
Does the presence of psoriatic arthritis affect your decision to use an anti-IL-17 or IL-23 drug in your psoriasis patients?
I tend to prefer IL-17s in patients with PsA as an indirect assessment of clinical trials suggests they are more effective than IL-23s (which fits my clinical experience) for PsA. IL-17s are also more effective for axial disease (IL-23s are not very effective in axial disease). If there is a history...
Do you have any concerns about administering a Vivitrol injection when a patient has severe coagulopathy and/or thrombocytopenia related to cirrhosis?
Although the risk of transaminitis is overall low, I do try to be more conservative when patients have evidence of severe cirrhosis or decompensated cirrhosis. If naltrexone is the best choice, I will typically start with oral naltrexone and check labs to ensure that they are stable. And if the pati...
Do you have any concerns about administering a Vivitrol injection when a patient has severe coagulopathy and/or thrombocytopenia related to cirrhosis?
Although the risk of transaminitis is overall low, I do try to be more conservative when patients have evidence of severe cirrhosis or decompensated cirrhosis. If naltrexone is the best choice, I will typically start with oral naltrexone and check labs to ensure that they are stable. And if the pati...
When do you consider Cheyne-Stokes respirations noted in download data from positive pressure machines to be normal vs abnormal requiring intervention?
I do not have great confidence in the algorithms for CSR detection in CPAP machines (both in terms of false negatives and positives). That said, I agree with Dr. @Dr. First Last that if there is an newly increased amount of central events or CSR on a CPAP report, that should prompt (at the least) a ...