Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you use buprenorphine in patients with chronic pain and prior history of opioid use disorder?
Absolutely. Buprenorphine is an excellent, evidence-based medication for patients with opioid use disorder, opioid use disorder with chronic pain, and chronic pain alone. The evidence in support of buprenorphine for pain has continued to accumulate over the past 10 years. At this point, I would neve...
Does the presence of psoriatic arthritis affect your decision to use an anti-IL-17 or IL-23 drug in your psoriasis patients?
I tend to prefer IL-17s in patients with PsA as an indirect assessment of clinical trials suggests they are more effective than IL-23s (which fits my clinical experience) for PsA. IL-17s are also more effective for axial disease (IL-23s are not very effective in axial disease). If there is a history...
How do you approach the management of patients who require nutritional restoration in the setting of a presumed functional GI disorder recalcitrant to behavioral medicine and pharmacologic therapies?
It certainly is a very good question if indeed the patient has functional disease; then, for sure, they need more than just my help. They probably need the help of a nutritionist, but even more so, they need perhaps psychiatric medication and the treatment of a behavioral therapist or psychological ...
Do you have any concerns about administering a Vivitrol injection when a patient has severe coagulopathy and/or thrombocytopenia related to cirrhosis?
Although the risk of transaminitis is overall low, I do try to be more conservative when patients have evidence of severe cirrhosis or decompensated cirrhosis. If naltrexone is the best choice, I will typically start with oral naltrexone and check labs to ensure that they are stable. And if the pati...
Do you have any concerns about administering a Vivitrol injection when a patient has severe coagulopathy and/or thrombocytopenia related to cirrhosis?
Although the risk of transaminitis is overall low, I do try to be more conservative when patients have evidence of severe cirrhosis or decompensated cirrhosis. If naltrexone is the best choice, I will typically start with oral naltrexone and check labs to ensure that they are stable. And if the pati...
When do you consider Cheyne-Stokes respirations noted in download data from positive pressure machines to be normal vs abnormal requiring intervention?
I do not have great confidence in the algorithms for CSR detection in CPAP machines (both in terms of false negatives and positives). That said, I agree with Dr. @Dr. First Last that if there is an newly increased amount of central events or CSR on a CPAP report, that should prompt (at the least) a ...
What are your thoughts on the results of the ALONE-AF trial and the safety profile of discontinuing anticoagulation post-ablation, provided there is no atrial arrhythmia recurrence?
ALONE-AF is another recent trial to challenge the current dogma. The 2023 ACC/AHA/HRS guidelines for AF recommend "In patients who have undergone catheter ablation of AF, continuation of longer-term oral anticoagulation should be dictated according to the patients’ stroke risk (e.g., CHA2DS2-VASc sc...
Do you avoid the use of GLP-1 R agonist therapy for treatment of obesity in patients with known gastroparesis?
Short answer: yes. Gastroparesis is a well-known side effect of GLP-1 RA therapy. It is dose-dependent, so some patients may tolerate smaller doses but not the highest ones. A recent head-to-head trial of semaglutide vs tirzepatide in obesity (Aronne et al., PMID 40353578) found similar rates of gas...
Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?
This is (and remains) a somewhat controversial question. ANCA titers do appear to rise in anticipation of disease flares and patients with persistent titers appear to have more flares. This is especially true for PR3 ANCAs. However, the proximity of flares to rising ANCA titers is not terribly close...
Do you take any special considerations when working up a pregnant patient for secondary causes of hypertension?
Pregnancy does affect the approach to secondary causes of hypertension evaluation. Because of the relatively high prevalence of pre-eclampsia (3-5% of pregnancies), hypertension occurring after the 20th week of gestation with new proteinuria often does not require additional workup. Patients could b...