Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you treat an isolated elevated total cholesterol in a post-menopausal patient who is otherwise healthy and has no significant CV risk factors?
This is not a simple yes or no question as asked, particularly with the limited information provided. Whether I would pharmacologically treat such a patient would depend on her actual lipid values. What are her LDL, HDL and triglyceride values? On the one hand, a total cholesterol could be elevated ...
What is your experience with iontophoresis for hyperhidrosis?
I always offer iontophoresis as a choice for my patients. One of the major roadblocks is affording the unit. In my experience, insurance does not uniformly cover the unit. Patients who have used it have had mixed success, mostly they report it was not effective in controlling their hyperhidrosis.
How do you approach treating younger patients with early female pattern hair loss?
I approach most younger patients similarly to older women with androgenetic alopecia. In younger patients, I try to do a more detailed history/exam to make sure they have no evidence of androgen excess, PCOS, and to identify if they have a strong family history of AGA. Spironolactone can be a good o...
When do you prescribe clascoterone cream for your acne patients?
Clascoterone cream can be beneficial in anyone who has acne. I do believe it should be used BID and I generally couple it with a topical retinoid. Remember that we are always trying to hit all four of the pathogenic targets in acne. Those targets are follicular hyperkeratinization, inflammation, C a...
How would you manage a patient with diffuse Systemic Sclerosis who develops severe rapidly progressive calcinosis?
Unfortunately, calcinosis cutis is a very challenging and frustrating manifestation of Systemic sclerosis to tackle. When extensive, response to trial of interventions is further unlikely or poor. The primary goal of treatment is to minimize symptoms and alleviate functional limitations rather than ...
How would you approach a stage II colon cancer with negative ctDNA but markedly elevated CEA level post-colectomy?
Thanks for the question. Highly complicated case. Few things matter here. First, what platform is used for ctDNA testing (whether tumor informed or not), and second whether this is T4 or T3 disease. It would be unusual to have high CEA but negative ctDNA in a true minimal residual disease (MRD). For...
Is there any role for iron chelation in a patient with iatrogenic transfusion-induced iron overload such as in patients with end-stage kidney or liver disease?
There is a point with transfusion that iron overload starts to cause significant organ damage. With the advent of deferasirox (Jadenu), oral iron chelation can maintain equilibrium with ongoing transfusion. I would not start till ferritin is 1500 or higher to avoid risk of chelation of other heavy m...
Do you consider Anti-carbamylated protein antibodies (anti-CarP) as having any significance in evaluation of patients if RF and ACPA negative and clinically no active synovitis yet widespread arthralgias and generalized osteoarthritis?
Anti-CarP has been touted as another biomarker for early RA with rates of positivity in ACPA and/or RF-negative patients ranging from 4.5 % in a recent study by Ricchiuti et al., PMID 35885566 to 23.6% in the French ESPOIR cohort. Ricchiuti described anti-CarP tracked the most closely with 14-3-3 et...
How will you approach tapering sarilumab in patients with PMR in remission?
Unfortunately, there is no data at the moment to inform decisions about the optimal duration of sarilumab treatment for PMR patients and how to discontinue this medication. The clinical trial that demonstrated efficacy was limited to 12 months and the drug was stopped altogether after that period. N...
Do you continue belimumab throughout pregnancy?
@Dr. First Last: @Dr. First Last is absolutely correct regarding the limitations of our studies regarding using belimumab in pregnancy.However, how much more evidence do we need?No one is going to perform a prospective randomized controlled trial. I and some others I know are feeling more comfortabl...