Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you uptitrate methotrexate dosing when a patient flares on a TNFi and methotrexate 15 mg weekly?
For mild to moderately low flare of disease, I would up-titrate methotrexate if no history of prior adverse effects at higher doses in the setting of normal renal function and no other medical comorbidities of concern. Many authors would still consider optimized dosing of methotrexate to be 20 to 25...
How do you manage/treat acute radiation-induced enteritis?
I have no problem with the excellent comments already made. However, I think it is important to add some comments. First - one needs to be sure that the patient truly has radiation enteritis. Many patients receiving abdominal radiation therapy have other issues that need to be explored first. For ex...
How do you determine the need to biopsy subcutaneous nodules in infants to rule out Infantile myofibromatosis?
For most subcutaneous nodules in infants of unknown etiology, I would check an ultrasound with doppler first as deep infantile hemangioma and other vascular lesions may be on your differential. If it is not vascular, and small and stable in size, it may be OK to clinically monitor. One may also cons...
Would you recommend avoiding use of bimekizumab in patients at higher risk of fungal infections such as patients with diabetes who are on SGLT-2 inhibitors which also increase the risk of fungal infections?
At this point, I do not see this as an issue. The increased risk seen with IL17 inhibitors is overwhelmingly oral candidiasis and not candidiasis elsewhere, or other fungal infections. In the clinical trials, this risk seems to be higher with bimekizumab than with secukinumab or ixekizumab, which ma...
What criteria are used to choose a specific dose of aspirin in ischemic stroke?
In my training and current practice, most stroke specialists have adjusted from the standard 81 mg aspirin dose (one-size-fits-all) to weight-based dosing. A meta-analysis of RCTs (Rothwell et al., PMID 30017552) suggests that low-dose aspirin may not suffice for stroke prophylaxis for patients who ...
What would be your approach to managing social anxiety in teenage patients with ADHD, doing well in regards to academic functioning with their stimulant medications?
Good question! So when the potential for comorbid diagnoses is raised, I take a step back. Some kids with ADHD become (appropriately) self-conscious and behaviorally inhibited in the academic environment due to their off-task behaviors, reduced academic performance, and challenges with basic behav...
What is your preferred initial imaging choice for a patient suspected of having renal artery stenosis who does not have any contraindications to imaging contrast media?
If the suspicion is for atherosclerotic-related renal artery stenosis (>55 years old, history of systemic atherosclerosis, tobacco use), then I start with a renal duplex ultrasound. Importantly, I do not get a renal duplex ultrasound on all patients with resistant hypertension. If the suspicion is f...
Will you incorporate ensifentrine in the treatment regimen of patients with COPD on baseline dual or triple inhaler therapy?
Novel bronchodilator. ENHANCE 1 and 2 showed improvement of lung function but cost can be a factor. $2,950 per month.
What parasites do you screen for in your workup of HES?
In my practice, if GI symptoms (particularly diarrhea), then culture for stool ova and parasites (broad screen). If there are no GI symptoms, then only screening for Strongyloides with a blood test for Strongyloides antibody. If there is a recent travel history or a patient immigrated from areas wi...
How do you approach managing nausea and GI side effects when initiating methotrexate?
There are several strategies to minimize nausea and gastrointestinal symptoms with the use of methotrexate. The medication can be taken with food, just not with caffeine. The dose can be split throughout the day it is taken such as half the dose in the morning and the other half in the evening. The ...