Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What topical and oral therapies do you prescribe for patients with recalcitrant melasma?
This is my Melasma algorithm: Hydroquinone triple cream qhs x 6 months + azelaic acid in the AM + tinted sunscreen Consider PO TXA (half of 650 mg tab bid), polypodium leucotomos bid (heliocare) Maintenance: stop hydroquinone and switch to compounded TXA/kojic/tretinoin combo cream qhs + vitamin C/...
What is the next step in management of a thyroid nodule that was biopsied and classified as Bethesda III, but Afirma genetic testing reveals parathyroid signature?
This is not an uncommon clinical presentation of intrathyroidal parathyroid adenomas, diagnosed incidentally on molecular profiling of cytological indeterminate nodules (CIN). These adenomas most often have the imaging features of a TIRADS 4 thyroid nodule (with well-demarcated margins, solid, profo...
How do you approach the use of GLP-1 receptor agonists for the management of patients with metabolically healthy obesity?
I want to define my understanding of the term “metabolically healthy obesity”. Generally, this is meant to describe patients with a BMI in the obese range but without hypertension, dysglycemia or dyslipidemia. Obesity is associated with a wide range of medical conditions beyond those three such as o...
Do you recommend the use of Korlym (Mifepristone) for patients with difficult to control diabetes and evidence of mild endogenous hypercortisolism of unknown source?
This is an ongoing question - stimulated by the CATALYST study. The impetus for the study is the observation that many persons with uncontrolled Type 2 DM will fail an overnight 1-mg dexamethasone suppression test (~25%). Subjects with ACTH-dependent hypercortisolism were excluded from further study...
Are there situations in which you treat calcinosis cutis that is not symptomatic for the patient?
There is NO treatment for either the prevention of calcinosis or the dissolution of calcinosis. Every 5-10 years over the past 40 years there have been potential treatments but none have been confirmed. I do not use anything specific for the asymptomatic patient. I do rarely recommend surgery by an ...
How would you approach management of a patient with rapidly progressive systemic sclerosis with worsening skin disease, myositis, arthritis, dysphagia and failure to thrive developing within 6 months?
This is a unique subset of patients with very aggressive disease and high risk for poor outcomes with myopathy, poor GI dysmotility, at risk for early PH. We tend to treat them aggressively. I would consider rapid escalation of immunosuppression such as MMF and consider IVIG up front as well, especi...
What is your approach to treating osteoporosis in patients post bariatric surgery?
While there is no guidance from the bariatric surgeons, I tend to avoid oral bisphosphonates in all patients with prior bariatric surgery. I am worried about the pill getting stuck independent of the type of surgery. Since we have IV bisphosphonates and denosumab I have good alternatives to oral bis...
How do you manage cases of levodopa intolerance due to nausea or drowsiness?
This is a great question. Side effects from levodopa can be challenging to manage. First, when you start carbidopa-levodopa, ensure you uptitrate it slowly to limit side effects. Carbidopa is most effective in reducing side effects when it is at least 75 mg total daily dose, thus, the 10-100 tablet ...
What are some strategies to help teach patients transitioning from pediatric to adult care to become more independent with respect to their care and less dependent on their caregivers?
A framework that has been helpful is Got Transition® that provides a structure for the approach in implementing a transition process. It is divided into areas to help health care providers, youth and young adults, parents and caregivers. Numerous resources are available for all stakeholders that inc...
Is there a maximum dose of potassium citrate you would use for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
I don’t think there is a maximum dose of potassium citrate. Hyperkalemia can occur, especially if GFR is impaired, and monitoring for that is important. In my experience, diarrhea is the most common dose limiting effect. Taste fatigue is common; fortunately there are multiple preparations available ...