Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is a reasonable class of antihypertensive to start in patients with HCM who remain hypertensive and symptomatic in spite of maximal doses of beta blockade or calcium channel blockers?
My answer is based on the experience and not the research data per se in HCM: I will add low-dose HCTZ (12.5 mg daily). It won't cause dehydration or hypokalemia and might do wonders in managing HTN in these patients. One of the cheapest and most effective! Or I would consider Spironolactone instea...
How do you approach interpreting a low titer dsDNA (such as crithidia 1:40 to 1:80) in the setting of a moderately elevated ANA without other specific features of SLE?
Serologies are not a diagnosis nor are they diagnostic. This patient does not NOW have lupus. Are there first-degree relatives with SLE? Does this patient have any other autoimmune disorders like Hashimoto thyroiditis? What to do? Follow-up and education. Routine follow-up and welcome phone calls to...
Is methacholine challenge on its way out?
I have not needed to order the challenge test for a long time now. I see the need for this test is declining.
What therapies have you found most effective in providing rapid improvement in patients with erythrodermic atopic dermatitis?
For me, the most critical part of treating erythrodermic atopic dermatitis is making sure you have the correct diagnosis. While biopsies can be helpful, my pathology colleagues have told me it can be difficult to determine the diagnosis in the biopsy of an erythrodermic patient. Likewise, labs or hi...
Do you perform routine interval lung cancer screening in non-smokers who are 1st degree relatives of patients with non-smoking related lung cancers with known EGFR mutations?
I would not. Although there may be a measurable increase in the risk of lung cancer detected in population studies, the absolute risk is probably far below the equivalent of even a low-risk, current or former tobacco user. This is a hard conversation to have with people who believe their risk to be ...
What is your approach to secondary prophylaxis for C difficile infection during concomitant antibiotic use in a patient with a history of C difficile infection?
We have been restricting secondary prophylaxis to those patients with severe protein malnutrition, receiving immunosuppressive chemotherapy, generally at the extremes of age who require unavoidable systemic antibiotics that cannot be withdrawn. Based on the 2024 paper by Ronza Najjar-Debbiny et al.,...
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...