Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What duration do you feel comfortable maintaining for the pediatric population on topical calcineurin inhibitors?
Topical calcineurin inhibitors are safe and effective for both the treatment and maintenance of atopic dermatitis in the pediatric population. The FDA approval age for topical tacrolimus is 2, however, many pediatric dermatologists and general dermatologists safely use these medications off-label in...
What biologic for psoriasis do you prescribe most often in patients with a history of malignancy?
I like an IL-17 inhibitor for psoriasis with a current or history of malignancy. IL-17 is involved with cancer neoangiogenesis, so blocking it may have an anti-tumor effect. This hasn’t been studied yet but it makes me feel better that the IL-17 class doesn’t have an increased risk of cancer and may...
Under what circumstances would you recommend the maternal RSV vaccine for a pregnant patient if nirsevimab will also be available for the infant after birth?
All mothers unless there is a specific contraindication to it.
Are there certain patients in whom you would avoid initiation of ULT during an acute gout flare?
Yes, I usually avoid it during first-time visits for gout flares. This is because the amount of information required during that visit would include: The acute gout flare management, and Information about gout in general. Commonly, this is in addition to other intercurrent medical problems. Addin...
How do you manage hyperalgesia in patients with sickle cell disease?
In addition to the obvious, such as PCA narcotics, Lyrica/Neurontin, and Toradol, I have success with IV Tylenol, Zyprexa, po L-Arginine (Morris et al., PMID 23645695) as well as Dexmedetomidine (Precedex), steroids (NEJM: Griffin et al., PMID 8107739) and acupuncture [Johnson et al., Alternative an...
What is your treatment algorithm for actinic cheilitis?
Great question. We prefer to use efudex for broad involvement or liquid nitrogen for more localized AK. Some people do use CO2 laser as another modality for treatment. You can also pre-prescribe valacyclovir to help prevent cold sore recurrence during treatment with laser.
How do you distinguish between primary and tertiary hyperparathyroidism in a patient with ESRD?
Almost all patients with hypercalcemia, hyperparathyroidism, and ESRD are going to have tertiary HPTH and not primary. Imaging will show diffuse hyperplasia and multiple nodules in tertiary and in the rare case of primary would expect to see a solitary nodule without hyperplasia of the other glands....
What is your approach for patients with recurrent nephrolithiasis who require daily use of acetazolamide for management of an unrelated chronic condition?
Acetazolamide, or other carbonic anhydrase inhibitors, typically increase urine pH into the low 7s. Normally, it is approximately 6.0. A mildly alkaline urine favors the formation of brushite and hydroxyapatite kidney stones. My first step is to contact the provider who prescribed the carbonic anhyd...
What are the clinical indications and major limitations of lipoprotein apheresis?
LDL apheresis is a procedure that selectively removes apo B-containing lipoproteins (so primarily LDL particles) from the circulation. Very simply - venous blood is withdrawn via IV, plasma separated by the machine (liposorber, FDA approved in the US), passed through a column which binds the apo B c...
What is the approach to use of ACE inhibitors for suspected scleroderma renal crisis in patients with only mildly elevated BP and renal artery stenosis?
I recommend using a short-acting ACEi, like captopril, to treat scleroderma renal crisis. You can start at 6.25mg TID and rapidly titrate up the dose to achieve blood pressure goals. The presence of renal artery stenosis (RAS) would not dissuade me from using an ACEi, if there is evidence of thrombo...