Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you define severe hypoxic burden on home sleep testing?
There seem to be two questions here. First, can you measure hypoxic burden on a home sleep test? The answer is that technically it can be done without great difficulty. However, as far as I know, there are no home sleep apnea testing devices that offer hypoxic burden as an outcome measure. Thus gett...
Do you ever taper or stop urate lowering therapy in patients who have had no gout flares and serum urate persistently below 6 mg/dl?
Part 1: Yes, but not often.Part 2: No, or extremely rarely. Read on. Urate lowering therapy (ULT) mobilizes monosodium urate (MSU) deposits and in time will resolve all of the clinical features of gout. The formation of these deposits results from sustained serum uric acid (SUA) elevations in excess...
How do you manage anticoagulation bridging for outpatient ESKD patients given concerns for bleeding risk with enoxaparin in this population?
I don't think we know what is the best route to take. Personally I still usually give lower doses of enoxaparin but it all depends on the circumstances. Why the patient needs anticoagulation? Does the risk of hospitalization out way the risk of increased bleeding from enoxaparin? Can the patient get...
How do you manage dry eye related to Pluvicto Lu-177?
This is a real but uncommon side effect of Pluvicto therapy. Per VISION, it will happen in maybe 3% of patients but almost never high grade. Interestingly, the absorbed dose for the lacrimal glands is 2.1 Gy/Gbq - which over 6 cycles full dose at 7.4 GBq/200 mCi per cycle means 92 Gy. There was a me...
When do you prescribe topical JAK inhibitors for adult patients with atopic dermatitis?
For adult patients with atopic dermatitis, I typically start with topical steroids with or without topical calcineurin inhibitors as maintenance therapy. If minimal improvement with topical steroids/calcineurin inhibitors, then I turn to other topicals including topical JAK inhibitors and/or crisabo...
When should I consider anticoagulation in an unprovoked upper extremity deep venous thrombosis?
Would do careful history like hunting Would do anticoagulation Age and fam hx may be helpful if one does thrombophilia workup
How would you manage a provoked blood clot for a patient who had been placed on low dose DOAC for history of unprovoked blood clot?
To clarify the scenario: the patient had an unprovoked VTE for which they are currently on low dose DOAC and now have experienced recurrence in association with a well-defined (as outlined in ASH guidelines Ortel et al., PMID 33007077) provoking event. A number of additional variables would weigh in...
At what point, if at all, do you decrease the frequency of or discontinue pegloticase infusions after achieving persistently low serum urate levels?
This is one of the most frequent questions physicians have about pegloticase therapy. To review, the goal of pegloticase therapy is to manage the gout patient who has an overwhelming disease burden from deposits of MSU in joints, bone and soft tissues. Frequent flares, chronic synovitis, tophi inter...
Is close observation a reasonable option for elderly patients with a small basal cell carcinoma of the face?
Yes, depending on life expectancy, logistics, and morbidity of treatment which would be minimal with RT.
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS. I.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). * I don't love carbidopa/levodopa for RLS. It very often causes augmentation.