Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you consider the clinical relevance of elevated serum B12 levels as a marker of underlying hepatic disease?
Elevated B12 levels have shown significant relevance and significance to many underlying conditions, particularly a high correlation with underlying liver disease. About 1 in 5 to 1 in 4 B12 levels >1000 pg/ml had a significant correlation. It is a prognosticator, in my opinion, and the literature s...
Do you utilize D-dimer to inform anticoagulation duration in the treatment of VTE?
I had developed a policy during my last eight or ten years of practice evaluating how long patients should be treated after a thrombosis and I'd like to share some impressions over these years as well as conclusions that I reached. These conclusions formed the basis of my approach to this problem. I...
Do you routinely check digoxin levels, and if so, when would you consider using Digibind in chronic digoxin use patients?
The subanalysis of the DIG trial gave some insight into the value of keeping digoxin levels below 1.0. If HF patients, I tend to look at the levels for that reason. I rarely use digoxin for AF as there is little evidence of benefit with some evidence of harm. Re: use of digibind, I limit this if t...
In older adults with chronic mild hyponatremia (Na 128–132) attributed to SSRIs but good psychiatric response, do you tolerate persistent hyponatremia, reduce the dose, or switch agents?
In my practice, I generally tolerate mild hyponatremia, Na>130, if asymptomatic and mood symptoms have good control. If there’s moderate hyponatremia, Na 125-130, I generally consider either changing the dose or the agent. If severe, Na<125, I would change the agent and likely avoid the entire class...
In older adults with chronic mild hyponatremia (Na 128–132) attributed to SSRIs but good psychiatric response, do you tolerate persistent hyponatremia, reduce the dose, or switch agents?
In my practice, I generally tolerate mild hyponatremia, Na>130, if asymptomatic and mood symptoms have good control. If there’s moderate hyponatremia, Na 125-130, I generally consider either changing the dose or the agent. If severe, Na<125, I would change the agent and likely avoid the entire class...
What are the most effective strategies for managing weight gain associated with antipsychotic medications?
In my experience, the following things have worked. Reassurance that it is a medication side-effect. Consider switching the anti-psychotic (or at least try and decrease the dose of the antipsychotic). Aripiprazole, Caplyta (Lumateperone), and Vraylar (Cariprazine) have shown benefits vis a vis weig...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
How do you manage patients with erosive pustular dermatosis?
First of all, it is very important not to miss underlying squamous cell carcinoma in cases labeled with erosive pustular dermatosis. I diagnosed moderately to poorly differentiated squamous cell carcinoma underneath the crusts in a couple of patients with known erosive pustular dermatosis of the sca...
Should low-intensity statins be favored to minimize the risk of diabetes onset while still offering cardiovascular benefit for patients with prediabetes where a statin is indicated?
While higher-intensity statins are associated with a slightly higher incidence of diabetes, it would not be recommended to start with low-intensity statins as there are no data to support this. Essentially, all of the CV outcomes trials with statins have been with moderate and high-intensity statins...