Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you recommend that a patient with stable coronary artery disease and well-controlled RA on a JAK inhibitor continue on their current therapy?
There is no simple answer for this. It is a difficult situation and I would consider a few things in making a decision about what to recommend. These include the course of the patient’s disease, e.g., duration and severity of disease, their current and previous medication history, and the severity o...
Is it true that a ferritin above 200 essentially rules out iron deficiency?
No, I do not think that a ferritin >200 ug/L essentially "rules out" iron deficiency. Ferritin is an acute phase reactant and can be elevated in myriad conditions including kidney disease, autoimmune disorders, etc. The transferrin saturation (measure of serum iron/TIBC) is an important marker of ir...
Does PT/PTT elevation due to severe vitamin K deficiency protect against thrombosis?
Yes, most of us think that vitamin K deficiency increases the risk for bleeding rather than protecting against VTE.
In patients with concurrent, CAD and atrial fibrillation, more than 1 year post-PCI, the most recent AHA/ACC guidelines state that “oral anticoagulation monotherapy is recommended over the continuation of oral anticoagulant therapy and a single antiplatelet therapy.” If this individual undergoes surgery, the anticoagulant will be held. Would you then bridge with aspirin?
This depends on the surgery and for how long anti-coagulation needs to be held. For example, if the patient is undergoing CABG, then the answer is yes, and aspirin seems reasonable. But for some surgeries, all 3 drugs would need to be held (ophtho or some neurosurgical/spinal procedures for example)...
Should lipid lowering therapy be started in patients with isolated elevation in lipoprotein (a) and minimal cardiovascular risk?
At the current time the answer would be "no" for someone with minimal CVD risk. There are not any currently available therapies for effectively lowering Lp(a) nor randomized trials demonstrating clinical efficacy, though this could change in the near future.
Should patients with mild subclinical hypothyroidism (TSH < 10 mIU/L) be treated with thyroid hormone replacement to improve their lipid profile?
There is a well-known association between untreated primary hypothyroidism and hypercholesterolemia with subsequent improvement of lipid profile following thyroxine replacement. However, the link between hyperlipidemia and sub-clinical hypothyroidism is less well understood. The all-important questi...
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...