Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach treatment change in patients with psoriasis who have been stable on an IL-17 or IL-23 agent but then begin to have breakthrough skin disease?
It really depends on where the patient is in their treatment journey. Patients who have tried and failed other biologics I try to optimize response by: increasing the biologic dosing frequency if insurance will allow, adding topicals, particularly newer ones like tapinarof or roflumilast, adding ph...
What is your experience managing patients with chronic spontaneous urticaria occurring only at night?
When I have patients with Chronic Spontaneous Urticaria (CSU) that is not responding like CSU should to medications, the first thing I wonder is if this is really CSU. In these situations, I will order additional lab work-up for CSU and conditions mimicking CSU, as discussed in a recent review in JA...
Do you recommend a waiting period to conceive after prostate radiation?
Yes, I typically advise that men and their partner use contraception for at least 3-4 months after the last fraction of radiotherapy based on the fact that the maturation cycle of sperm is estimated at approximately 2- 2.5 months. I typically counsel men prior to treatment that there is a chance (bu...
What parameters would you use to monitor and interpret iron levels in a hemochromatosis patient where ferritin is unreliable due to underlying chronic inflammation?
The biggest question in these situations is whether the patient truly has iron overload vs. just high ferritin. If iron sat is not elevated, true iron overload is very unlikely. If both ferritin and iron sat are elevated, but they don't have a homozygous C282Y genotype, I make sure that the patient ...
Do you routinely use cefdinir for the treatment of common infections diagnosed in the outpatient setting such as CAP, uncomplicated UTIs?
Not routinely. More expensive than equally effective alternatives.
What is your preferred method for latent tuberculosis screening prior to outpatient hemodialysis initiation for a patient with new dialysis requirements?
Definitely Quantiferon testing. It can be done at the same time as the hepatitis B blood test. The patient does not have to come back and have it read a couple of days later.
Are drug challenges after serum sickness-like reactions useful in delabeling the allergy?
Too unpredictable each time.
Do you have to extend treatment for acute Lyme disease if a patient is on high dose steroids for another indication?
I am unaware of any evidence to support longer-term therapy in such a setting. I am quite sure no such study has ever been done. Standard therapy for early Lyme disease is 10 days of appropriate antibiotics. Extending to 20 days would likely do no harm to the patient, but may not be necessary, and t...
Are you comfortable utilizing Stelara (ustekinumab) as biologic treatment of psoriasis for patients with a history of severe latex allergy?
I don't have a lot of data to go on. On the one hand, I would be comfortable, as I doubt there would be any problem as long as the patient didn't touch the latex in the needle cover. But since we have many products without latex, perhaps it would be prudent to use those first. If other options were ...
How do you approach the management of poorly controlled migraines during pregnancy?
This is an excellent question and area of frequent discussion. You can start with Lidocaine nerve blocks: occipital, supra-orbital, and temporal. Sometimes, just IV fluids will help for acute migraines. Other options include Reglan, caffeine, and APAP. If in the second trimester, I will do steroid t...