Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you have any pearls for how to manage OSA with CPAP in older adults with cognitive impairment?
I try to involve a partner or other family member in the process, including getting a sleep study in the first place. If the study shows moderate or severe sleep apnea, especially with substantial oxygen desaturation, I remind the patient and partner that use of CPAP will help the patient's memory. ...
For patients over 70 with elevated ASCVD risk but no prior cardiovascular events, do you ever recommend continuing or initiating low-dose aspirin?
Yes, I might still recommend low-dose ASA for primary prevention for someone over 70 if the patient is very functional.
Is adequate BP control sufficient enough when titrating spironolactone therapy for primary hyperaldosteronism treatment?
Good blood pressure control is one of the three major goals of medical treatment of primary aldosteronism. Titrating spironolactone (or eplerenone) to an adequate blood pressure (often with reduction or cessation of other anti-hypertensives) is often the first goal met with dose adjustment. The seco...
After what time frame off GLP-1 RA therapy should you restart at the lowest starting dose?
When a patient has stopped an incretin agonist for more than 2 weeks, I suggest at least restarting at a reduced dose. After 3-4 weeks, I would suggest restarting at the lowest or next to lowest dose. Restarting at a higher dose with anti-nausea medication such as ondansetron may be an option for so...
For patients on medications that are known to cause photosensitivity, would you counsel them to avoid laser hair removal or laser therapies?
"Known to cause photosensitivity" is almost every drug, but actually isn't all that common. I Rx doxycycline all summer and maybe see a possible reaction every few years. Variables are the dose of the drug and the amount and wavelength of light, but mostly studies are lacking. A test spot might giv...
How would you approach an asymptomatic older female patient with eosinophilia to 17,000, present for years, and normal eosinophilia workup including marrow and negative FLIP1?
Interesting case. Eos have been in the 17K range for years? Was it incidentally noted? Could just be idiopathic HES. I would worry about cardiac infiltration in an older patient, but if there have never been cardiac issues and no evidence of a myeloid variant, I would probably defer to the patient a...
How do you counsel your patients with diabetes that tighter glycemic control could be harmful as they age when they've been committed to a goal A1c% <7.0-7.5 for many years?
I counsel my elderly patients and their families that at a certain age, the risk of developing long-term sequela of diabetes (eye disease, kidney disease) becomes lower because those things take many years to develop. However, elderly people are more vulnerable to medication side effects, so we adju...
What is your approach to anticoagulation in patients with hypertrophic cardiomyopathy and an apical aneurysm?
Patients with hypertrophic cardiomyopathy and an apical aneurysm are at higher risk for sudden cardiac death (hence the 2a guideline recommendation for primary prevention ICD) and thromboembolism. Rowin et al., PMID 29122139 previously noted that non-anticoagulated HCM patients with apical aneurysms...
How do you recommend counseling patients on the prognosis of advanced cancer as a generalist who is not highly specialized in cancer literature or cancer-directed therapies?
Generalists can accurately prognosticate on the order of days to short months without specialized knowledge when caring for people with advanced cancer because the prognosis is often clinically obvious, and because most cancer-directed therapies take weeks to months to work (a patient may not live l...
What patient factors most strongly influence your decision to start biologic agents in mild cognitive impairment?
1.Absence of need for anticoagulants ( this is exclusionary) 2. Absence of APOE e4 homozygosity (although we do treat e4 homozygotes, but with much greater precautionary measures - especially the dosing protocol) 3. High functional ability, and adherence to healthy lifestyle measures (exercise, die...