Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your preferred topical retinoid for acne?
I generally start with tretinoin 0.025% cream as the first-line for acne. If the patient has a history of eczema or sensitive skin, then I would start with adapalene 0.1% gel/cream and then ramp up from there if they tolerate it for a few months without side effects.
How would you treat ESRD patients on hemodialysis with recurrent AV fistula thrombosis found with low protein C activity?
I assume that the patient described in the vignette has a negative family and personal history of VTE. PC (and PS) deficiencies are relatively common in ESRD patients. The low levels are thoughts to reflect a combination of true (acquired) reduction and the assay interference rather than true defici...
Does IVIG or subcutaneous Ig interfere with monoclonal antibody therapy (i.e. dupilumab, infliximab, rituximab, etc)?
I definitely agree with Dr. @Dr. First Last concerns. For what it’s worth, I use a lot of IVIG in combination with monoclonal medications in my myositis clinic, and have anecdotally noted multiple instances in which I feel that the efficacy of one of those monoclonals seems to have been worse when t...
How do you address patient concerns regarding the necessity of REMS monitoring when prescribing sparsentan?
I point out to patients that sparsentan itself did not have an increased incidence of liver function abnormalities in trials, and that this REMS monitoring is required out of an abundance of caution because of liver function abnormalities seen with other anti-endothelin drugs like bosentan. Of cours...
How would you manage a patient with Takayasu arteritis controlled on TNFi who develops erythema nodosum that is only partially responsive to NSAIDs?
Erythema nodosum and pyoderma gangrenosum (as well as erythema induratum) are well recognized as cutaneous manifestations of TAK. Unfortunately, we do not know how often cutaneous and the vascular disease are decoupled from each other due to a lack of available data. Most case series document associ...
Does oral semaglutide provide similar cardiovascular risk reduction benefits as injectable semaglutide?
Novo Nordisk, the manufacturer of oral and injectable semaglutide, just released positive topline results in its SOUL cardiovascular outcomes trial (n=9,650) for its oral semaglutide in people with T2D and established CVD and/or CKD. The trial met the primary endpoint demonstrating a statistically s...
What is your approach to therapy in patients with progressive Scedosporium pulmonary infection who are not candidates for surgical debridement?
Scedosporium species are increasingly common clinical isolates in patients with bronchiectasis (both CF and NCFBE). There are precious few publications describing these infections in immune-competent hosts, but it seems that these infections tend to be symptomatic (rather than asymptomatic colonizat...
How do you dose oral tranexamic acid for melasma?
I typically do 325 mg BID (1/2 tab of 650mg) during May-Sept then off in the winter. Double layer of sunscreen: chemical then mineral over it. Two favorites are La Roche Posay Cooling Water Lotion SPF60 then Eucerin Sensitive Mineral Agave SPF35 over that every morning regardless of the days activit...
What workup do you consider for a developmentally typical child with multiple large café au lait macules but no other signs of neurofibromatosis?
The likelihood that this is NF1 depends somewhat in part on the age of the child in question. In infants and toddlers, cafe-au-lait macules are usually the first and only clinical sign of NF1. Most children with NF1 will develop skin fold freckling in early childhood, and the majority (probably 60-7...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...