Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should GLP-1 agonists be held during chemotherapy?
I think there are several aspects to this question. First, is there evidence that as a class GLP-1 RAs increase the risk of cancer or worsen prognosis during cancer? I could find nothing to raise concerns about outcomes. One recent report even showed a decreased risk of some cancers with GLP-1 RA co...
How do you determine whether to continue anti-dementia medications (such as cholinesterase inhibitors) for patients with dementia when enrolling in hospice?
In most cases, recommending discontinuation of anti-dementia medications when someone is eligible to enroll in hospice due to end-stage dementia is reasonable. Symptomatic benefit is less likely to be noticeable or meaningful at this stage (and benefit is small to modest even at earlier stages). Abi...
Are there other scenarios besides prior history of TIA or stroke or LV dysfunction in which systemic anticoagulation for LV non-compaction would be considered?
There is limited data in this area, but LV non-compaction by itself is not always an indication for anticoagulation. In addition to prior history of TIA, stroke or LV dysfunction, other conditions that anticoagulation should be considered include a history of atrial fibrillation or LV thrombus. The ...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
How do you approach laboratory evaluation in patients with fatigue?
First search for evidence by history and physical examination for any evidence of inflammation. If there is tailor the lab workup rather than ordering tests as screening tools. ESR and CRP to start with. Anything more without a reasonable a priori likelihood of the targeted diagnosis is just asking ...
In your clinical practice, do you find that patients with moderate dementia due to Alzheimer's see much benefit from increasing donepezil dosing from 10 mg/day to a higher dose such as 23 mg/day?
I am very reluctant to increase the dose of donepezil to higher than 10 mg daily. The study in 2010 by Eisai that led to the FDA approval of the 23 mg showed marginal benefits and significantly higher side effects (particularly GI) than the 10 mg standard tablet. I have also seen the 10 mg tab presc...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
What are the reasons for SLE specific labs to turn negative?
I agree and appreciate the answers by Dr @Dr. First Last and Dr @Dr. First Last. My answer may be stating the obvious, but I think it is important to mention that lupus is not infrequently over-diagnosed and overtreated. Serologies are sometimes over-interpreted with low-titer antibodies labeled as ...
When should one consider obtaining a cardiac MRI in ischemic stroke patients?
This is a terrific question. Cardiac MRI is increasingly utilized in the diagnostic evaluation of ischemic stroke and can uncover clinically covert cardiovascular disease. The clinical utility in ischemic stroke is most in patients with concern for LV thrombus (low EF or recent anterior ST elevation...