Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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.
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
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...
How many days prior to elective major surgery do you recommend holding oral GLP 1 R agonist therapy?
Zero. Or, I suppose, if you're having surgery early in the morning, one.This has gone back and forth, but the most recent guidance from the ASA (with other societies concurring) has been that most patients can continue their GLP medications as normal preoperatively, with higher-risk people being rec...
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...
What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?
The main goal of this trial was to get RA patients off of therapy and to see whether they would flare or maintain remission. We didn’t expect that the ultimate likelihood of success or failure was going to be primarily related to how long it took to do that. While a gradual withdrawal of the drug ma...
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...
When considering deprescribing antihypertensives in older patients, how do you approach prioritization of which antihypertensives to target first?
When deprescribing antihypertensives in older adults, my approach is individualized, goal-concordant, and iterative with close monitoring after each step. Every patient is a little different, so there isn't one class of antihypertensives I always deprescribe first. My general rule of thumb is that w...
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...
What specific criteria or patient conditions would make you hesitant to use fluoroquinolones early in the treatment course for managing MSSA joint infections with oral antibiotics?
For MSSA joint infections, I have moved away from using FQ to using high-dose cephalosporins as a step-down therapy, particularly cefadroxil 1 g twice daily, given less frequent dosing/increased adherence. Considering the risk-benefit analysis, I prefer using FQ as an oral option in polymicrobial an...