Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach management of new onset ILD in a patient with RA who is otherwise well controlled on methotrexate or leflunomide?
We do not have any randomized controlled trials for DMARDs in RA-ILD. Most of the data is case series or retrospective analysis. Nonetheless, we can use current data to at least make clinical decisions until we receive more direction from high-quality clinical trials. We now know that in general met...
How do you approach the management of ADPKD in pregnancy, considering the need to stop tolvaptan therapy?
I generally consider transition to pregnancy with respect to both tolvaptan and ACEi along the same time frame... discuss when initiating counseling about becoming pregnant and discontinue use when patient is about to start actively trying to conceive.Additional counseling may be warranted re: blood...
When do you think physicians should seriously consider prescribing PCSK9 inhibitors for the prevention of heart attack and stroke in people with ASCVD or diabetes, based on the results of the VESALIUS-CV trial?
Although I checked 'high lipoprotein (a) as a reason to go with a PCSK9 first, I would almost never do it is practice. Statins first and then add a PCSK9 if LDL is above my goal for the patient. I might use a lower dose of the statin to get 35% lowering and then add the inhibitor if the patient was ...
What is your preferred treatment for actinic cheilitis?
PDT is effective as well as an ablative laser for long-term control. Efudex or imiquimod for multiple weeks is good for localized or milder disease. Consider getting a biopsy if you’re concerned for invasive SCC. Encourage them to use sunscreen too.
What is your approach to young teenagers with acne who have extremely sensitive skin, cannot tolerate typical acne regimens, cannot tolerate oral antibiotics, and refuse Accutane?
The formulation of benzoyl peroxide encapsulated in silica shells is extremely well tolerated by sensitive-skinned individuals. I was involved in pre-approval studies and found it remarkably well tolerated in such patients.
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
Do you consider using buspirone for the management of anxiety in older patients?
While buspirone has been FDA-approved for the treatment of generalized anxiety disorder (GAD) and for short-term relief of anxiety symptoms in general since the 1970s, it is not generally considered a first-line treatment, despite its low misuse potential as a non-benzodiazepine. There are no large ...
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
How do you treat depression symptoms in patients with Parkinson's disease?
The management of PD-related depression can be a little complicated, but there are several proposed algorithms out there based on varying degrees of evidence. Personally, I like this reference (Pontone and Mills, PMID 33648830) as a place to start. It makes 3 key points: Distinguishing between PD an...