Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend adjusting the duration of a drug holiday based on the specific bisphosphonate used when treating osteoporosis?
If there has been a satisfactory response, the drug holiday for alendronate can be 2 years while zoledronic acid, which is more tightly bound to bone, can be stopped for three years.
What are reasonable alternatives to invasive angiography for CAV surveillance in patients who are a few years out from cardiac transplant with impaired renal function?
In our practice, we move to PET-CT on Year 3 if the prior 2 angiograms with IVUS did not show accelerating disease. The issue with CAV is that there is not much to do about it reactively. The best you can do, is switch to an mTORi regimen early and optimize lipids. IVUS is useful for that reason. Be...
How do you manage nephrotic range proteinuria in a pregnant patient with a known history of diabetic nephropathy prior to pregnancy?
Interesting question. Part of this depends on what one thinks of the etiology of the nephrotic syndrome. With a history of diabetic nephropathy, the odds are this is a continuation/natural worsening of the underlying diabetes, and hence there is no specific therapy exists. Hence, a renal biopsy woul...
Do patients with central adrenal insufficiency on maintenance hydrocortisone therapy require doubling of their corticosteroid during chemotherapy cycles?
I would follow the same sick day rules. If the patient is not feeling well with nausea, diarrhea, or worsening fatigue, the same rules of doubling the GC dose would apply. In cases of severe vomiting and not being able to keep the double dose of GC, parenteral GC injection and going to the ED for fl...
How long should patients with atrial fibrillation who are already on systemic anticoagulation and are status post TAVR and PCI 6 months ago remain on Plavix?
If PCI was done for a plaque rupture event I.e. ACS, then DOAC + plavix for a year is the current SOC. For non ACS PCI, DOAC + plavix for 6 months, followed by DOAC mono Rx is a reasonable option.
Which class(es) of antihypertensives do you recommend for first-line therapy for hypertension in severe aortic stenosis?
Most beneficial data on ACE inhibitors.B blockers are to be avoided if associated AR but prior apparent contradiction is no longer valid and some benefit in outcomes based on their effects. Exact Aortic Stenosis substrate and comorbidities to determine which drugs to benefit. ARB's role is probably ...
What treatment would you offer a patient with extensive lymphangioma circumscriptum intermittently covering the entire abdomen?
I would consider sirolimus (rapamycin) to shrink the lesion to a size that could be surgically excised.
What is your approach to differentiating diabetes insipidus from primary polydipsia in the outpatient setting?
I usually do overnight dehydration tests for 12 hours and if fasting AM urine osmolality is >600 DI is less likely. If urine osmolality is low with high serum sodium it indicates DI, whereas with primary polydipsia the serum sodium is low with low urine osmolality.
What is your approach for severe SCLE in patients unable to tolerate HCQ?
30% of subacute cutaneous lupus erythematosus (SCLE) is worsened by or caused by drugs, especially PPIs, calcium channel blockers (CCBs), thiazides, minocycline, and anti-fungal meds. Very different from other drug-induced disorders, the culprit drug could have been started months to years (as long...
How do you approach a patient with stoma bag adhesive allergic contact dermatitis?
To keep the area dry, I have patients use Cavilon spray and Skins, an antimicrobial spray.