Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
The CGRP antibodies and gepants are my preventive treatments of choice. In fact, I hardly ever prescribe anything else anymore preventively, including botulinum toxin. Tolerability issues I hardly ever encounter with the antibodies, but sometimes I do with the gepants, in particular fat...
How do you counsel patients on wearable heart monitor devices when they ask about specific products and diagnostic accuracy of these devices available on the market?
It depends on the device. If a patient is experiencing palpitations infrequently, or there is an ongoing need to identify the cause of palpitations, I typically recommend a consumer-facing ambulatory ECG device that is FDA-cleared. They are quite accurate for detecting AFib and ectopic beats such as...
How do you treat disruptive mood dysregulation disorder?
DMDD is quite an enigma. The whole concept of irritability, which transcends many diagnoses, is also interesting. DMDD was meant to avoid overdiagnosis of moody disruptive behavior as bipolar. Since many of those kids are not suffering from bipolar disorder, I thought it was a great move. Unfortunat...
How do you discuss the importance of ongoing lifestyle-based interventions when starting a GLP-1 agonist for medically relevant obesity (i.e., with comorbid conditions)?
I discuss the importance of ongoing lifestyle interventions by going back to the primary research for the corresponding GLPs. I point out the fact that in many of the trials, both the control group and the experimental groups would have some form of therapeutic lifestyle change (usually a mix of edu...
What typical lab tests do you send off for evaluation of neuropathy?
Not too much has changed in over a decade regarding the recommendations on how we should approach initial laboratory testing in patients presenting with a neuropathy syndrome. Specifically for cases of distal symmetric polyneuropathy, the AAN practice parameter (reaffirmed in 2022) by England, et al...
How do you choose among SSRIs and dosing strategies for the management of behavioral and psychological symptoms of dementia?
The best supported SSRI for BPSD generally is citalopram. Much of this came out of the CitAD trials [1]. This primarily showed citalopram may be useful for hyperactive behaviors, irritation, but also for depression and anxiety [1, 2]. The effect and response to citalopram, though, may be affected by...
When do you start steroids for radiation pneumonitis?
Great question on a relevant clinical topic. It's very important to remember that pneumonitis is a diagnosis of exclusion. Sometimes, if the timing is right and the patient's presentation is typical, there is a tendency to move quickly to the conclusion that the symptoms are caused by pneumonitis. R...
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...
How do you approach the management of ADPKD in pregnancy, considering the need to stop tolvaptan therapy?
I generally consider transition to pregnancy with respect to both tolvaptan and ACEi along the same time frame... discuss when initiating counseling about becoming pregnant and discontinue use when patient is about to start actively trying to conceive.Additional counseling may be warranted re: blood...
When do you think physicians should seriously consider prescribing PCSK9 inhibitors for the prevention of heart attack and stroke in people with ASCVD or diabetes, based on the results of the VESALIUS-CV trial?
Although I checked 'high lipoprotein (a) as a reason to go with a PCSK9 first, I would almost never do it is practice. Statins first and then add a PCSK9 if LDL is above my goal for the patient. I might use a lower dose of the statin to get 35% lowering and then add the inhibitor if the patient was ...