Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When, if ever, would you consider tapering patients started by another provider on low-dose, as-needed lorazepam for insomnia without a history of cognitive impairment or substance use disorders?
It is important to have a conversation with your patient about potential side effects and benefits of discontinuation of benzodiazepines, especially when it is used for an indication like insomnia. I have had this conversation with any of my patients who are using benzodiazepines. Benzodiazepines ar...
What are your thoughts about lion's mane supplementation to slow the decline or improve cognitive capacity for those at risk of dementia?
Lion's mane is the latest in the ever-evolving list of supplements that have a whiff of animal data, very small human trials, or frankly, anecdotal evidence. A decade ago, it was coconut oil; last week, it was lithium. There will always be suggestions of the benefit of this or that. Currently, there...
What are your thoughts about lion's mane supplementation to slow the decline or improve cognitive capacity for those at risk of dementia?
Lion's mane is the latest in the ever-evolving list of supplements that have a whiff of animal data, very small human trials, or frankly, anecdotal evidence. A decade ago, it was coconut oil; last week, it was lithium. There will always be suggestions of the benefit of this or that. Currently, there...
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...
How would you approach the consideration of continuing or ceasing colonoscopy for colon cancer screening in a relatively fit man in his 80s without a history of polyps on prior colonoscopies?
For someone in his 80s who has received good screening and never had polyps, continuing colonoscopy brings little benefit. The risks and difficulties from the procedure become greater with age, so, for most older adults, stopping routine screening is usually the better option for geriatric care. Whe...
How would you approach the management of asymptomatic ALT and GGT elevation in an older adult patient with depression with psychosis and without history of hepatitis who recently had dose of quetiapine increased and new initiation of SNRI?
The answer when you suspect drug-induced liver injury depends on the X elevation above normal of ALT and bilirubin. In addition, exclusion of other coexistent factors, i.e., alcohol use, metabolic risks, or other medications. From liver tox, quetiapine may elevate liver tests in 30% of patients. Bel...
What therapies do you recommend for patients with recalcitrant seborrheic dermatitis?
Topical roflumilast is easily the most effective thing I've ever seen. Prior to that being available, here were the go-to drugs for difficult seb derm: Itraconazole 200 mg qd until better, then 200 mg qd on weekends long term Fluconazole, exact same regimen if itraconazole not accessible Oral Roflu...
How do you counsel older adults regarding the use, dosing, and safety of CBD-containing products for insomnia?
When counseling older adults on CBD use for insomnia, I usually explain that evidence for safety and effectiveness is limited. Most products are not FDA-approved, and their labeling, purity, and dosing can be inconsistent. It’s important to review the patient’s comorbidities and medications closely,...
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...