Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?
This is an important concept because anyone using tocilizumab will eventually wrestle with this question. The question, though, does not tell you whether this is the first time a practitioner sees the liver enzyme elevation, or how high the liver enzymes rose. Since everyone should have had a lipid ...
How long do you anticoagulate for cirrhosis patients who have portal vein thrombosis extending to the mesenteric veins?
I recommend indefinite anticoagulation for most patients with portal vein thrombosis, and at least 3-6 months if there are risk factors for bleeding. Once they complete anticoagulation for the first 6 months, I re-evaluate their risk of recurrent thrombosis vs bleeding, and if there is an underlying...
How do you approach managing nausea and GI side effects when initiating methotrexate?
There are several strategies to minimize nausea and gastrointestinal symptoms with the use of methotrexate. The medication can be taken with food, just not with caffeine. The dose can be split throughout the day it is taken such as half the dose in the morning and the other half in the evening. The ...
When and how should we be stopping GLP-1 Receptor Agonist/Dual Agonist therapy?
I usually continue for 3-4 years, the tapering down slowly over 1 year period, buy then the set point for energy expenditure and appetite likely is changed.
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...
What topical therapies and procedures do you recommend for patients with atrophic acne scarring?
If the patient has hyperpigmentation, then some sort of topical lightening approach (i.e., tretinoin/kojic acid/niacinamide/Vit C/tranexamic acid, etc) or chemical peels. For the actual scarring, assuming that the acne process has burned out, the most ideal procedure depends on the particular type o...
How do you manage dry eye syndrome due to lacrimal or meiobian gland dysfunction after external beam radiotherapy?
I have also found autologous serum (AS) or platelet-rich plasma (PRP) eye drops/tears to be extremely useful (provided by an ophthalmologist). Dry eye can also be exacerbated by graft vs. host disease, which I have anecdotally seen worsened within radiation fields and is characterized by a lasting m...
How do you approach the frequency of DEXA scan monitoring for older adults on bisphosphonate therapy during the course of therapy?
Depends who you read. ACP: Recommendation 4: ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women. (Grade: weak recommendation; low-quality evidence) [1] Monitoring wasn't addressed in the 2023 update. ACR: For adults continuing...
Do you ever use Joyrnavx in a patient with end stage liver disease?
I have not encountered this novel oral small molecule medication Suzetrigine for the management of acute moderate to severe pain (FDA approved indication) in my patients with cirrhosis. The drug received FDA approval in Jan 2025 after two phase III trials where it was used for pain control after b...