Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you prioritize dietary modifications and exercise over early pharmacologic interventions, such as metformin or insulin, for women diagnosed with gestational diabetes?
Most women with gestational diabetes are diagnosed in their late second/ early third trimester after a standard oral glucose tolerance test. Some women may be diagnosed earlier in their pregnancy and perhaps even had undiagnosed pre-gestational diabetes. Rarely, a patient can develop type 1 diabetes...
How do you approach the management of patients on lamotrigine who develop a minor rash?
Lamictal rash can be dangerous but if we stop or switch lamictal for any rash during treatment we can run out of options soon. Get a good history and pictures, if possible. How long have they been on lamictal and was there a recent dose change or did the pharmacy change their generic brand? Have an...
How often should TSH levels be monitored in patients with a history of Graves' disease who are in remission with negative TSI/TBII antibodies and off medical therapy?
If Anti-thyroid drugs are discontinued when an TSH receptor antibodies are still positive, recurrent hyperthyroidism often develops within a few months. On the other hand, if the drug is discontinued when antibodies are negative (not “normal“ but still detectable), then recurrent hyperthyroidism is ...
Do you have concerns with the use of oral contraceptives in patients on JAK inhibitors given the black box warning for thromboembolic events?
I would be concerned with the use of estrogen-containing OC especially in patients who are smokers, obese, and/or with a strong family history of CV disease. However, I know many rheumatologists who would still cautiously prescribe JAK inhibitors to these patients, particularly in the absence of add...
Would you start anticoagulation in a patient with RCC and related (tumor) thrombus with extension to renal vein and further?
Tumor thrombus is an intraluminal extension of tumor mass, rather than a true thrombus. There is no evidence that anticoagulation improves outcomes in tumor thrombus (Marcoux et al., Blood 2019). Primary management is surgical resection, typically as part of radical nephrectomy for localized RCC or ...
What suspected myositis manifestations drive you to start empiric therapy before the work-up is complete?
When evaluating a patient with myositis, I would consider starting immediate therapy when 1) my suspicion of myositis is high (i.e. characteristic rashes, compatible constellation of symptoms, very high CPK) and 2) the symptoms are severe. It would be the severity of the symptoms that would drive ho...
What is your approach to elevated CK in patients without clinical or serologic evidence of immune mediated myopathy?
Thanks for your great question: This is especially important because we are much more likely to see patients sent for "elevated" CPK than patients with myositis.Unfortunately, I think that the answer to the approach depends a lot the circumstances, including (1) how elevated is the CPK, and (2) how ...
Do you favor the use of maximal inspiratory/expiratory pressure measurement or supine spirometry in the evaluation of a patient with suspected respiratory muscle weakness?
In practice, we often perform both in the same session. Supine spirometry has the advantage of assessing the orthopnea that is a common complaint among my patients with neuromuscular disease. Also, many of our patients report that the MIP/MEP maneuver is difficult to perform and they feel it underes...
Do you recommend adding low-dose Aspirin for primary prevention in patients with Type 2 Diabetes on Eliquis for another indication?
Most guidelines and standards of care do not generally recommend aspirin therapy for primary prevention in patients with type 2 diabetes. As such, I do not generally recommend it unless their 10-year ASCVD risk is > 20% then I would have a discussion with the patient about low-dose (81 mg) aspirin t...
How would you approach management of a young male patient with discoid lupus who has had minimal response to hydroxychloroquine (and subtherapeutic whole blood levels) who continues to use tobacco products?
First, is he taking his HCQ (55% chance he is not)? Check a trough whole blood HCQ drug level and you want it to be 1000 - 1200 ng/mL (that is my goal in uncontrolled lupus; 750 - 1200 is fine in lupus under remission per Garg et al., PMID 37667434). Thanks, @Dr. First Last for reminding me. :-) Wh...