Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your target or goal lipoprotein (a) level for patients on PCSK9 inhibitors for either primary or secondary prevention?
Let me compliment the clinician who submitted the question because he/she measured lipoprotein (a) [Lp(a)] in the first place. Lp(a) was first described in 1964, but its contribution to atherosclerotic vascular disease risk has only recently attracted widespread attention. Part of that attention is ...
How do you address/manage the recreational use of dextromethorphan (sometimes called "robo-tripping") that has risen to the level of use disorder?
This problem of "robo-tripping" has become an increasingly observed clinical issue, namely the misuse of dextromethorphan with cough medication (Robitussin). This is often in conjunction with alcohol misuse. We recently published a case report in The American Journal of Drug and Alcohol Abuse (Ledwo...
How do you use cardiac biomarkers, if at all, in prognostication for patients with ischemic stroke?
Would you consider restarting a SGLT2i at a reduced dose in a patient who you previously discontinued the medication because of an associated significant decline in eGFR?
Restarting an SGLT2i in a patient after a severe episode of AKI requires careful decision-making and patient agreement. If the AKI episode was deemed related to volume depletion (hemodynamically mediated AKI), I restart the SGLT2i at a lower dose. At the same time, I re-counsel the patent on fluid i...
Has there been an observed interaction between ACE inhibitors and development of angioedema in a block demarcated superficial radiation therapy treatment volume (ex. lip)?
ACE inhibitors are the leading cause of drug-induced edema in the US (ACE inhibitor-induced angioedema - UpToDate). It was likely not related to the radiotherapy.
How do you approach treating disseminated granuloma annulare?
I have not found disseminated GA associated with diabetes in my clinical experience even though it has been reported in the literature. Similarly, disseminated GA has been reported with SLE in the literature and I have seen that once in my experience. I would only check for diabetes or SLE if there ...
What is current best practice with regards to antibacterial prophylaxis in patients with hematologic malignancy and resolved neutropenic fever (>72 hours)?
For patients with febrile neutropenia, recent literature has demonstrated that early de-escalation and discontinuation of antibiotics may be safe for some patients. Since ECIL guidelines have recommended modification of the initial regimen at 72-96 hours based on the patient's clinical course and mi...
What is your approach to tapering treatments for patients with bullous pemphigoid?
Oral steroids are generally for acute management and can be tapered as other drugs like doxycycline kick in...typically over a month. Doxy controls most patients pretty well and is safe for long-term Rx. I generally try to taper doxy after a few months without symptoms. Dupilumab is also useful when...
Do patient co-morbidities impact when you prescribe oral jak inhibitors?
Great and pertinent question in our field. Autoimmunity doesn’t make me less likely to prescribe, actually more likely as there is plenty of case report and case series data on JAKi being used in a variety of autoimmune conditions. Certainly, dyslipidemia (think MACE), VTE risk, and malignancy risk ...
What is your approach to managing the initial acne purge while on isotretinoin?
Just start at a lower dose. Add prednisone if really needed. And please don't call it a purge.