Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What dose and duration of steroid therapy do you employ while starting mycophenolate in an outpatient with relatively stable CTD-ILD?
This is a great question since it raises some important concepts about treatment response in this patient population. Providers often talk about the presence or absence of a steroid-responsive process, and if so, whether a steroid-sparing agent would be beneficial. My bias is to avoid steroids in an...
Do you recommend thiamine for patients presenting with acute symptoms of TGA?
Thiamine might be considered, especially if the patient has features of Wernicke-Korsakoff syndrome. However, if the patient has TGA, no drug treatment is needed since the amnesia resolves on its own.
How do you approach management of ILD in the presence of weakly positive RF and ANA but no other objective systemic findings of connective tissue disease?
This issue comes up frequently in our combined ILD/Rheumatology clinic and my pulmonary colleagues are typically looking at me for an answer as to whether I think the biomarkers are relevant to the patient's ILD. Low-level ANAs and RFs are not uncommon in the general population and can result in ove...
Do you feel high dose Symbicort or Dulera is appropriate to use for SMART despite these doses not being studied in clinical trials?
One of the primary purposes of SMART therapy is to provide extra doses of ICS to patients inadequately controlled enough to use rescue inhalers. The other major purpose is to do this with a single inhaler instead of 2 or 3. So if the patient's baseline asthma is severe enough to require high-dose Sy...
Would you consider over-the-counter dextromethorphan (low dose, slow titration) as augmentation in MDD?
Just one comment to clarify what might be a title/question mismatch:Augmentation of bupropion with dextromethorphan makes sense, given the positive results from the bupropion/dextromethorphan polypill. As to results, I'll leave that to others, as I haven't used this strategy very often.Augmentation ...
What is your treatment algorithm for treating patients with lichen planopilaris?
LPP can be localized and smoldering or widespread like a wildfire. All patients are treated with a potent topical steroid solution. For some that is all that is required. For those with severe or active disease I will start an oral agent such as doxycycline or hydroxychloroquine and consider intrale...
Can Droxidopa be used for augmenting orthostatic hypotension treatment in patients who are already on midodrine and/or fludrocortisone?
I routinely combine droxidopa with fludrocortisone just as I would midodrine and fludrocortisone when orthostatic hypotension is refractory to tolerated doses of monotherapy. The use of droxidopa and midodrine is something I do less commonly, or frankly just rarely. They compete for the same recept...
What are your management strategies for patients with end stage kidney disease on hemodialysis who develop hypercalcemia of immobility?
I have seen this situation from time to time. First, I would make sure the patient is not getting any calcium or vitamin D-containing products. Then would try to use a lower calcium bath. Unfortunately, many units are unable to lower the calcium bath below 2.0 mEq/L currently and a lot of time that ...
How would you approach the staging and treatment of extranodal marginal zone lymphoma of left and right lacrimal gland?
This entity is described in literature as "ocular adnexal lymphoma". I usually screen those patients for Chlamydia infection and would empirically consider a 3-week course of doxycycline especially if the disease is indolent behaving clinically and there is prior serologic evidence of Chlamydia infe...
Is there a role for beta-lactams as step-down oral therapy for uncomplicated gram-negative bacteremia?
For carefully selected patients - yes. Patients who might be good candidates for transition to oral beta-lactams for uncomplicated gram-negative bacteremia would-be patients: clinically stable, improving on IV abx with functioning GI tracts (no issues with absorption of antibiotics) not immunocompro...