Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there a role for empiric scabies treatment in itchy patients without clear clinical signs of scabies?
I have seen many astute clinicians miss scabies or consider it after months of treating for AD with biologics and other systemics (including myself). Though this is very rare my personal rule of thumb is to treat with oral ivermectin if at any point patient is not responding the way I expect to trea...
What additional therapies can be helpful for vaginal dryness causing dyspareunia in premenopausal woman already using lubrication?
Lubricants are a good first-line option and are used as needed with sexual activity. The two main types recommended are water-based or silicone-based lubricants. Water-based lubricants are generally safe to use with condoms and sex toys and are easy to clean. They may also dry out more quickly and r...
Would you consider anabolic osteoporosis therapy in a young adult male with multiple non-traumatic vertebral compression fractures and low bone density for age (Z-score -2.6)?
I think a young male with multiple minimal trauma vert fractures and low BMD is appropriate to consider anabolic therapy. Of course, a thorough workup needs to be done to determine if there are any treatable causes of bone loss. If it is determined that he has “idiopathic osteoporosis” then treatmen...
What are your criteria for starting tolvaptan in adult patients diagnosed with autosomal dominant polycystic kidney disease?
This question is probably a bit too broad to answer in detail here, but in broad strokes, depending on the age, imaging criteria (Mayo class / total kidney volume), and kidney function of the patient, as well as other clinical factors, you assess the patient's risk of rapid disease progression to ma...
Would you continue Forteo treatment past the recommended 2 years if T scores remain low and procollagen (P1NP) is elevated and if so, how would you monitor response?
I would offer a third year of a PTH analogue if the BMD response is less than a -2.5 T Score. I would follow quarterly serum calcium levels and a BMD for 1 year to assess the effects.
What criteria do you utilize in deciding when to treat or not treat frequent VPC’s?
Symptoms (burden and severity) PVC burden (>15-20% may lead to a cardiomyopathy) Presence of LV dysfunction Interference with bi-ventricular pacing PVCs triggering VT or VF
What is your approach to further work-up and management of neutropenia in patients with SLE/RA overlap?
This is an interesting situation that comes up in the routine evaluation of patients with rheumatoid arthritis and other autoimmune syndromes. The normocellular bone marrow suggests a peripheral destruction, in general, and raises some concerns for antibodies directed against neutrophils. These are ...
Do you recommend patients temporarily hold cilostazol prior to and after a kidney biopsy?
Kidney biopsy is considered a high-risk bleeding procedure by SIR (Society of Interventional Radiology).Cilostazol is a PDE inhibitor leading to the inhibition of platelet aggregation. The Drug has a half-life of 10 hours. In the past, it was recommended to stop the drug at least 24 hours before a p...
Do you prescribe linezolid to patients who are concomitantly on an SSRI?
Yes, cautiously, especially when LZD is the best or only option. Recent Eur J Clin Pharmacol July 2023 meta-analysis involving 84 publications found an observed rate of < .01%; another study Shi et al., PMID 37301313 found a similar rate (1/1743 persons, 0.06%). Holding an SSRI for a day or two prio...
Would you consider transitioning patients older than 75 years of age with coronary disease from statins and/or other lipid-lowering agents to PCSK9 inhibitors given concerns for polypharmacy, provided their LDL levels remain at or below goal?
We do not have any data to suggest PCSK9i are better than statins, and all of the PCSK9i outcomes data are on top of statins. Data show generally that lower is better, and there isn’t a “floor” to benefit. That said, if I have someone on statin + ezetimibe who then gets LDL-C very low on a PCSK9i, I...