Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you continue to use Botox to treat chronic migraine in a patient who becomes pregnant?
First of all, my use of botulinum toxin for the preventive treatment of chronic migraine has dramatically decreased since I started working with the CGRP antibodies in the context of clinical trial research in 2012. I find them to be much more effective than botulinum toxin, equally well if not bett...
When (if ever) do you check for anti-platelet antibodies for workup of thrombocytopenia?
Routinely available anti-platelet antibody tests have a sensitivity too high and specificity too low to be of much clinical use. A patient's response to first line therapy (steroids or IVIg) is most telling and if there is no response, a bone marrow is warranted as it would be atypical for ITP. Ther...
Have you found success in managing refractory hidradenitis suppurativa with ertapenem?
Ertapenem is the magic bullet for HS. It is the one therapy that you can count on to shut down the disease, even in the most severe cases. So, why isn't it our first-line therapy? It only works while the patient is on therapy, and it can't be continued indefinitely owing to the risks associated with...
Do you avoid SSRIs in patients with a history of RCVS?
SSRIs are on a long list of medications associated with RCVS. The condition is relatively rare, and a very low percentage of patients have recurrences. If there is a strong indication for antidepressants, I would treat them with appropriate warnings.
How do you evaluate patients with suspected pseudo-dementia?
I am very careful about diagnosing a functional cause for cognitive impairment. I typically get vitamin B12 and TSH levels, and also get a neuropsychological evaluation. They are usually able to pick up underlying behavioral disorders or poor effort. If unrevealing, and there are no obvious risk fac...
What is your approach to using apremilast for psoriatic arthritis in patients with history of depression?
Depression is a common comorbidity of psoriasis and psoriatic arthritis (20% at least mild and 14% at least moderate in a recent meta analysis). Depression is a known but relatively infrequent side effect of apremilast (<1.8% in clinical trials). It is important to screen for depression in all patie...
How do you approach the workup and management of patients with suspected functional neurologic disorders?
This is not really an answerable question. I would re-frame the question, because it really depends on the kinds of symptoms they have and the neurologic exam that is performed. I disagree with neurologists who say that "functional neurologic disorders" are a diagnosis of exclusion. That is absolute...
How do you approach treating patients with delusions of parasitosis who can not tolerate an antipsychotic?
I continue to switch them until I find one they can tolerate. My typical approach is Abilify 2 mg daily and increase by 2 mg every other week until on 10 mg daily if tolerable. If they can’t tolerate that, then I switch to Risperdal and if they can’t tolerate that then I switch to pimozide. If they ...
How do you approach NSAID use in patients on SSRIs?
This is a good question, the combined RR for NSAID+SSRI/GI complications is ~12. I generally avoid the combination and utilize topical NSAIDs if possible. I also discuss the possibility of switching patients from a 'traditional' SSRI to duloxetine, which is FDA approved for the treatment of primary ...
What is the best way to manage severe claustrophobia and anxiety for Thermoplastic masks?
I’ve found that P.O. uptake of benzodiazepines is notoriously unreliable, and often the severity of patients’ anxiety isn’t apparent until after the process has begun. Because of this, I stock IM hydroxyzine (a.k.a. Atarax or Vistaril), which is a great non-narcotic old-school anxiolytic with a reli...