Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What treatments would you recommend for rosacea patients with persistent, soft/non-fibrotic cysts on the dorsal nose recalcitrant to chronic doxycycline and topical therapies?
Can consider a trial of a different oral antibiotic (such as a macrolide), or intralesional triamcinolone if lesions are discrete. However, I would likely proceed with a course of oral isotretinoin if there are no contraindications, given the recalcitrant nature of the disease. Doses usually range b...
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.
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...
Which patients with intermediate and high risk prostate cancer should not receive androgen deprivation therapy?
Based on randomized trials that didn't exclude patients with cardiac risk factors, an overall survival benefit has been observed for intermediate and high risk localized prostate cancer. Review of RTOG studies has not detected an increase in cardiovascular events. That said, appropriate management o...
What is the likelihood of a successful pregnancy following pelvic irradiation?
This is a very important question. The risks on future fertiltiy from radiation therapy to the abdomen/pelvis are twofold.1) Dose to the ovaries. The LD-50 to the ovaries may be as low as 2 Gy, thus the risk of ovarian dysfunction and premature menopause, is high. 2) Dose to the uterus leading to po...