Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you monitor risk of erythrocytosis from testosterone use for female to male transgender patients?
I utilize the Endocrine Society's guidelines for identifying secondary erythrocytosis secondary to gender affirming hormone therapy (GAHT) (PMID 28945902). For initial monitoring, at baseline and then every 3 month hematocrit for the first year and 1-2 times yearly thereafter is typically implemente...
Do you recommend placement of a backup AV fistula in an advanced CKD patient who is planning to do peritoneal dialysis?
This is a controversial point for which I don't believe there to be great data. An old study in the British literature- I can't get my hands on it right now- purportedly demonstrated that only 7% of such fistulae were ever used/ useable. With improved fistula technique and survival this number is un...
What is your approach to inhaler therapy in a patient with asthma who cannot be on an inhaled corticosteroid due to ocular disease?
I use LABA/LAMA combination.
How do you approach and manage anorexia and appetite loss in people with advanced cancer?
Anorexia/cachexia is often distressing to patients and families and it is this distress that is the target of many of the interventions for this syndrome as there are, in general, no effective therapies. Patients and families are routinely battling over the lack of eating as this causes further disc...
When should vaccines be given if not received prior to the start of high dose radiation (40-50 Gy) to the spleen?
Mortality due to infections is increased in asplenic individuals as well as those receiving radiation therapy to the spleen. The risk is low but measurable. For example, in a large Childhood Cancer Survivor Study, the cumulative incidence (35 years) after splenectomy of late infection-related mortal...
Which IV medications do you offer for outpatient headache infusions?
Eptinezumab (Vyepti) in a dose of 100 or 300 mg. It is a CGRP antibody marketed for the preventive treatment of episodic or chronic migraine. However, in a randomized, double-blinded, placebo-controlled trial treating patients with 100 mg IV for moderate or severe migraine headache, it met the FDA-d...
What treatments and resources have you found helpful for ichthyosis vulgaris patients?
I also make sure to get my patients enrolled in Beiersdorf's free Aquaphor/Eucerin program. They help patients with ichthyosis by providing free products to them. Here's how to do it: Beiersdorf/Eucerin – Aquaphor has a program for families that use large amounts of Aquaphor. The company will send ...
Do you consider anti-viral prophylaxis in patients taking JAK inhibitors who have recurrent uncomplicated Zoster infection, but would prefer not changing therapy?
This is a really good question without a clear answer. Patients on JAK inhibitors are not only at increased risk for VZV but also for recurrence. Data from Kevin Winthrop and colleagues examining the tofacitinib database revealed that patients with RA and PSA are at 10 to 20 times increased risk for...
How do you manage musculoskeletal pain in men receiving androgen deprivation therapy for non-metastatic prostate cancer?
This a very good question. Because bone pain can be a symptom of "benign" bone health issues without bone metastasis and because of the patient population demographics including risk factors, we obtain baseline bone health screening on most patients who must undergo Androgen Deprivation Therapy (ADT...
How do you counsel premenopausal women with BRCA1 or BRCA2 mutations on the need for bilateral oopherectomy?
I typically mirror the NCCN guidelines in this area. For those with BRCA 1 mutations, I recommend RRBSO between age 35-40 after completion of childbearing. Because those with BRCA2 mutations typically have onset of ovarian cancer later, it is reasonable to delay until age 40-45. Counseling needs to ...