Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Which types of patients do you treat with prolonged antibiotics before obtaining a CT sinus?
If the patient has had symptoms of chronic rhinosinusitis for more than 7 days I would give a 10-day course of Levoquin. The symptoms I look for include purulent post-nasal drainage, nasal congestion, and lethargy. If the patient does not respond in 203 days, I would obtain a sinus CT.
Is there a role for nintedanib in the management of patients with radiation-induced pulmonary fibrosis?
There is no phase III evidence I am aware of on the benefits of nintedanib in the prevention of radiation-induced pulmonary fibrosis so it is not a drug I use. There are a few case reports and some pre-clinical studies suggesting an effect. There is a small (34 patients) randomized phase II study th...
At what point in GCA management do you typically introduce tocilizumab?
I typically introduce tocilizumab as first line therapy in combination with prednisone in patients who do not have a contraindication. The GIACTA trial demonstrated the superiority of TCZ+prednisone x 6 mos over prednisone alone x 6 or 12 months with numerically fewer serious adverse events. Given t...
When and how do you taper off cabergoline therapy for treatment of microprolactinoma?
If patient does not desire fertility and microprolactinoma is stable or smaller, cabergoline can be tapered off.
Do patients with an elevated IGF-1 level and features of acromegaly need to have confirmatory growth hormone suppression testing with OGTT?
OGTT is not always needed. In the presence of clinical features of acromegaly, a frankly elevated IGF-1, and a pituitary adenoma visible by MRI glucose suppression test is not necessary.
Are you offering GLP-1 agonists to patients with CKD and diabetes mellitus?
According to KDIGO 2022, GLP-1RA are second line DM Rx (see fig 3: Rossing et al., PMID 36272755); this class of medications still awaiting a CKD-dedicated RCT such as FLOW (Rossing et al., PMID 36651820). However, secondary outcomes of CVOT show kidney protective effects for some GLP-1RAs (non-exen...
Would you escalate therapy in a patient with rheumatoid arthritis without synovitis, but a new rheumatoid nodule?
The appearance of a new nodule in someone without synovitis is puzzling. If it is truly a rheumatoid nodule, their RF should be positive. These patients have a heightened risk for the development of full blown RA in the future. However, the appearance of a nodule without synovitis being present does...
Is there any role for 25-OH Vitamin D testing in patients older than 75 years old in the general population?
The recent Endocrine Society Guideline on Vitamin D no longer recommends testing for vitamin D status unless there are unusual circumstances. The Guideline however recognized that approximately 20% of adults greater than 75 years of age are vitamin D deficient i.e. 25-hydroxyvitamin D <20 ng/mL. The...
Would history of breast cancer deter you from using ospemifene for severe vaginal dryness/dyspareunia?
The agonistic/antagonistic activity of ospemifene in different tissues that express estrogen receptors is incompletely understood and therefore, I would have reservations about using this agent in women with hormone receptor positive breast cancer. In fact, looking at the labeling information of osp...
What therapies have you had success with in treating CARP when they have failed minocycline?
Treating with oral ketoconazole or fluconazole in two separate doses a week apart can be helpful in treating concurrent tinea versicolor that may be present along with CARP.