Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What dosing range of doxycycline do you recommend for short-term and long-term management of ocular rosacea?
Short term, Doxycycline may be used at 100mg BID for 2-4 weeks, especially in severe cases. It can then be tapered to 100mg QD once a partial clinical response is documented, but where residual disease and symptoms still exist, or to 50mg QD if there is a complete clinical response. Longterm, doses...
How do you approach hormone replacement therapy for premenopausal patients following pelvic radiation therapy?
Most patients who undergo pelvic radiation will become menopausal. Physiologically, the outcome is similar to surgical menopause because sufficient doses of radiation result in complete loss of ovarian function. In contrast, after natural menopause, the ovaries continue some types of endocrine funct...
What is your approach to the use of NSAIDs in patients with a history of gastric sleeve/bypass?
The use of nonsteroidal anti-inflammatory drugs in someone with a history of gastric bypass and/or sleeve surgery is risk prohibitive. Not only is there a risk of gastrointestinal bleeding, but more importantly, there can be effects on the previous surgical, anastomosis, and other untoward effects. ...
How do you approach recurrent costochondritis in an SLE patient with nephritis who is otherwise controlled on MMF and HCQ but can't take NSAIDs?
I do the following: I reassure them it is not cardiac or pulmonary. If I'm not 100% sure, then I send to cardiology (especially in my high-risk patients) because patients can occasionally chest wall tenderness for non-musculoskeletal chest pain. Ask them to work on proper posture (I'm convinced tha...
What treatment would you use in a patient with osteoporosis on denosumab for 10 years who develops ONJ at a site of an old implant?
A bone formative agent as teriparatide.
When do you consider stopping denosumab when a patient with osteoporosis is otherwise tolerating it without issues?
This is a matter of "style" more than anything. I continue Prolia and have many patients now exceeding 10 years - up to12 years, without any apparent safety issues. I realize we are in a "data-free" zone after 10 years, but as rheumatologists, we are frequently giving monoclonal antibodies for perio...
For a patient obtaining significant benefit and no side effects from pentoxifylline/Vitamin E for radiation-induced vulvovaginal fibrosis, do you continue treatment longer than 6-7 months or discontinue?
I reassess these patients at 3 and 6 months, regardless of site (gyn or breast). If the patient is benefitting from the trental/vitamin E but still has significant fibrosis, I continue these meds for up to 2 years.
What is your threshold to start triple therapy in mild to moderate asthma/COPD overlap with minimal functional limitation?
The question is vague as it does not define functional limitations. If the patient has frequent exacerbations (not defined by the question), Triple therapy would be recommended. If she just has minimal SOB for instance an exercise induced type picture SABA/LAMA prn with LABA ICS (w/o LAMA) would be ...
How would you manage a patient with erythrocytosis of unknown cause in pregnancy?
Pregnancy invokes changes in the blood volume and erythropoiesis: the plasma volume expands, erythropoietin production falls, and the hematocrit (don't use the hemoglobin level) declines (the hydremia of pregnancy) until the last trimester. So that by the third trimester, the hematocrit varies betwe...
How would you approach a low to moderate titer of one of the APLS antibodies in a patient with a strong family history but no personal history of thrombosis?
I do not do anything as there are no data to support intervention in this case.