Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What alternative medications other than dapsone would you consider for dermatitis herpetiformis in a sulfa-allergic patient?
Dapsone is a sulfone and in my experience, does not usually cross-react with sulfonamide-allergic patients (e.g., bactrim allergies).
Does 4G/5G polymorphism in the plasminogen activator inhibitor (PAI-1) gene increase the risk of thrombosis?
Venous thromboembolism (VTE) is a classical example of a multifactorial disorder where genetic and environmental factors interact to result in VTE. Of the genetic disorders, in isolation, many are weak risk factors but when combined with other genetic or one or more environmental risk factors increa...
Is there any benefit of using aspirin to mitigate VTE risk in testosterone-induced polycythemia?
Erythrocytosis is a common adverse effect of testosterone therapy, and results from several studies suggest an association between elevated hematocrit (Hct) and risk of VTE (Braekkan et al., PMID 19833630; Ory et al., PMID 35050717). There is currently no data to support the routine use of aspirin o...
For how long would you hold anticoagulation before percutaneous left atrial appendage closure with Watchman or Amulet devices?
Elective left atrial appendage occlusion with both Watchman and Amulet systems most often utilizes continuous uninterrupted oral anticoagulant administration (including the day of procedure) along with intra-procedural heparin to ACT 250-400 during implant. Procedural heparin is reversed immediately...
Do you ever consider close clinical monitoring over antifibrotic therapy in patients ascribed an MDD diagnosis of IPF who have normal lung function and are asymptomatic?
Idiopathic pulmonary fibrosis is by definition a progressive disease with high mortality, thus, clinical practice guidelines would recommend treatment at diagnosis. Based on US and UK epidemiologic studies, IPF has an average life expectancy of 3-4 years without antifibrotic treatment. Furthermore, ...
What patient characteristics prompt you to prescribe vericiguat for patients with heart failure with reduced ejection fraction who are already on standard therapy?
When considering the addition of vericiguat for patients with HFrEF who are already on standard therapy, several patient characteristics guide my decision-making process: Recent Decompensation: I particularly consider vericiguat for patients who have experienced a recent episode of heart failure de...
How often do you check renal function panels for patients with recurrent nephrolithiasis?
Interestingly, most patients with recurrent kidney stones have normal or near normal GFR. I check them annually when I do imaging and 24-hour urine supersaturations looking for metabolically active stone disease. For those patients with decreased GFR, I recheck them at the same frequency, I would c...
At what point do you prescribe duloxetine for the treatment of AIMS (aromatase inhibitor induced musculoskeletal syndrome)?
Results from the SWOG-1202 clinical trial were recently presented in the SABCS 2016 conference in December. (Editor note: Full publication in JCO, 11/2017). Duloxetine is a SNRI approved to treat depression, anxiety, neuropathic pain, and chronic pain syndromes including fybromyalgia. This study enr...
How do you counsel patients on semaglutide or tirzepatide in light of potential cancer risks?
Use of GLP 1 RAs has sky-rocketed in recent years due to what seems to be a positive class effect on T2DM, weight loss, renal outcomes, cardiac outcomes and hepatic outcomes. I am not aware of any signals of increased malignancy risk. A brief literature review found meta-analyses showing possible be...
Do you always stop dexamethasone at discharge for patients admitted with COVID requiring respiratory support (as done in the RECOVERY trial), or are there situations in which you will prescribe it to complete a 10-day course?
Great question. Generally, I don't continue dexamethasone if they are no longer wheezing or generally feeling back to their baseline. Sometimes, I will extend the course if the patient has been in the hospital several times for COPD, just to see if I can keep them out of the hospital longer. But the...