Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage me anticoagulation in a patient with May Thurner Syndrome, who does not have history of thrombosis, and becomes pregnant?
Watch dimers, if neg, no anticoagulation; if positive, anticoagulation.
Should insulin be started early (prior to optimization of other anti-hyperglycemic medications) in patients with mild-to-moderate diabetes and hypertriglyceridemia refractory to statin and fibrates?
Not necessarily. The goal should be achieving optimal glucose control to improve triglyceride levels. This can be accomplished with non-insulin agents, such as GLP-1 agonists and others, that can have beneficial effects on triglycerides.
Should Orlistat be considered in the management of hypertriglyceridemia?
While there are no controlled trials addressing this issue, it is certainly a reasonable option which I have used in some patients with Familial Chylomicronemia Syndrome. It will help to reduce the generation of chylomicrons and therefore the subsequent risk for hypertriglyceridemic pancreatitis. Ma...
How should very low T scores (worse than -3) be interpreted in very thin patients (BMI < 18)?
It would be very helpful to know the age of the patients. Age is well documented to be independently inversely related to fracture risk for the same T score. Low BMI places less stress on the skeleton and in response the skeleton maintains lower bone mineral content i.e. bone mineral density. There ...
Should patients with asymptomatic GH deficiency be treated with GH replacement therapy if they have prior known severe CAD?
Yes, GHRT should be discussed with GHD adults independently from symptoms. There is no evidence that GHRT increases the risk of CAD, and in fact, it may be beneficial due to the lowering of total and LDL cholesterol (this is a theoretical benefit, as I am not aware of any study that showed that GHRT...
Should a short trial of androgen therapy be used in patients with primary adrenal insufficiency suffering from persistent fatigue and hypoactive sexual desire despite sufficient glucocorticoid and mineralocorticoid replacement?
Considering that adrenal glands are an important source of androgens in women, this approach, especially in symptomatic patients, seems reasonable. I usually use DHEA supplements starting at 25 mg daily and then adjust the dose based on the DHEAS and testosterone levels. Most patients require 12.5 t...
Should testosterone replacement be stopped in elderly men who suffered acute stroke even when testosterone levels have been stably in the low-to-mid normal range?
Recent data are reassuring with regard to the cardiovascular safety of physiologic testosterone replacement in older men. The TRAVERSE study of 5,246 men 45 to 80 years of age who had preexisting or a high risk of cardiovascular disease and were randomly assigned to a testosterone gel or placebo sho...
Would you recommend prescribing testosterone replacement therapy to reduce osteoporosis fracture rates in men with hypogonadism?
100% yes. Especially if improved quality of life may be realized. Practitioners need to understand that TRT supersedes physiologic testosterone when it comes to quality-of-life benefits, especially INJ testosterone. That's assuming even normal testosterone to begin with. Clinical real-world benefits...
What is a reasonable duration of time for dual anti-platelet therapy in patients who have undergone placement of a covered coronary stent?
First of all, this question hasn't been studied and second, few of us have a huge experience. Based on a series of exactly 2 patients, the possibility of thrombosis is ever present. I personally continue DAPT indefinitely in this circumstance. I am reluctant to stop it entirely; for elective procedu...
How often do you monitor labs such as complete blood count, liver function panel, and urine protein in a patient with cystinuria receiving tiopronin?
I check patients newly started on tiopronin or after an increase in dosage about one month later. Assuming the lab results are normal, I do not continue to check them. I think late adverse reactions must be very rare. Stephen B Erickson, MD