Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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 ...
Would you try combination ketorolac and cortisone injections in a patient with severe knee OA who refuses surgery and had partial responses to injections of cortisone and ketorolac separately?
Clinical use of intraarticular injection of ketorolac has gained some popularity, especially in the orthopedic community, although the I.A. route is not an approved indication by the FDA. As such, its use is off-label, which may make reimbursement difficult in the U.S. Nonetheless, there have been s...
What holistic treatments do you recommend for patients with migraine without aura?
Before considering alternative or holistic treatments, first, assess whether both preventive and abortive treatments have been taken correctly and if there is no evidence of medication overuse. Cost and side effects often limit compliance. Lifestyle modification (which could be broadly considered as...
Do you avoid sodium zirconium cyclosilicate use in your patients with ESKD and hyperkalemia who also have peripheral edema?
I don't. The extra salt intake is a problem but so is the hyperkalemia. In general, I am conservative in giving potassium binders in hemodialysis patients because of the risk of polypharmacy.
For which patients or under which circumstances do you recommend a 9-month over a 6-month course of isoniazid for treatment of LTBI?
The preferred regimens now for the treatment of latent TB infection are shorter rifamycin-based regimens. We have options of 3 months of isoniazid and rifapentine given once weekly, or 4 months of rifampin given daily, or 3 months of isoniazid and rifampin given daily. Isoniazid-only regimens are no...