Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What treatments have you found most effective for cholestatic pruritus?
My experience is mainly in Sjogren's or Sjogren's with PBC, ursodiol has been effective. Occasionally, I have used hydroxyzine or H1+H2 blockers. In Sjogren's where the skin biopsy has shown significant lymphocytic infiltration, mycophenolate or a calcineurin inhibitor trial has lead to the resoluti...
How do you approach the treatment of microscopic colitis?
If there is a temporal association between starting a drug like NSAIDs, PPI, SSRI, statin in the onset of diarrhea deny would stop the medication before beginning pharmacological therapy for microscopic colitis. If there is no potential drug trigger, and I stratify my treatment based on severity of ...
What is the anticoagulation recommendation for a chronic DVT?
Simply having a chronic DVT is not an indication for anticoagulation. In general, acute provoked VTE requires a minimum of 3 months of anticoagulation. For an unprovoked VTE, there are scoring systems that guide towards limited duration vs long-term of anticoagulation. So it depends on where the fin...
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)?
Angioedema may occur at any time during treatment with ACE inhibitors and may even continue after the medication is discontinued. While there is no direct evidence that radiation therapy alone triggers angioedema in patients taking ACE inhibitors, if the radiation therapy affects the tissue where an...
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...