Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you treat a woman with iron deficiency anemia, unresponsive to iron sulfate, and with allergic reaction to iron sucrose?
Needs more information. Is the issue unresponsiveness or intolerance? Frequently, patients report GI intolerance and don't really take it. It's crucial to inquire about this and consider trying different preparations to find a suitable option. What was the nature of the iron sucrose allergy? Sometim...
What oral therapies do you most commonly recommend for skin cancer prevention?
I don't use a lot of oral medications for this problem. The one I use most is Nicotinamide and I think the data is really only supported for SCCs, not BCC. In the past, I have used low-dose oral retinoids but this can be challenging depending on co-morbid conditions and lesions tended to spring up w...
How do you manage asymptomatic patients with incidental findings of the carotid web?
Terrific question. I would certainly not pursue interventional treatment in asymptomatic patients with carotid web. The role of aspirin is also debatable and not conclusively proven. I would ensure vascular risk factors are controlled and consider starting aspirin if otherwise indicated based on ove...
In an RA patient with positive RF and CCP abs who is stable on TNFi biologic, how would you approach incidentally found low titer positive DsDNA abs?
ANA and dsDNA antibodies can generally be overlooked in seropositive RA if one is planning to treat (or is treating) with TNF antagonists. There are rare instances of TNFi-induced lupus-like diseases but these are not predicted by pre-existing ANA or dsDNA antibodies.
Do you combine oral and topical NSAIDs for pain relief?
This is a challenging situation but a clinical scenario frequently faced by a practicing rheumatologist. Topical NSAIDs rarely achieve a measurable blood level, and frequently can provide good pain relief at the site of symptoms. It can be a useful way to reduce the milligram dose of an oral NSAID, ...
How do you manage pityriasis lichenoides chronica (PLC)?
If you are confident in the diagnosis of PLC, which isn't always easy to be, then no systemic workup is needed. The issue is the spectrum of disease and feeling confident you are truly dealing with PLC and not a related disorder with a possible risk of progression (LyP et al). Given that oftentimes ...
How would you manage a patient with osteoporosis on denosumab who develops significant renal insufficiency where it is difficult to continue denosumab due to increased risk of hypocalcemia (i.e. eGFR in the low 20’s)?
This is an interesting question. Denosumab, unlike bisphosphonates, does not have a warning about use with renal insufficiency. However, denosumab does reduce osteoclast activity for a few weeks after the injection, and this can cause hypocalcemia in patients with renal insufficiency as these patien...
In which patients with chronic kidney disease and low 25-OH vitamin D levels do you prefer weekly ergocalciferol to daily cholecalciferol supplementation?
Ergocalciferol (D2), the plant-based form of Vitamin D, and cholecalciferol (D3), the animal-based form, are essentially equivalent in potency with perhaps a small, clinically insignificant edge favoring D3. They both can be given at long interdose intervals; monthly doses provide the same impact on...
What is your blood pressure goal for the first three months after kidney transplantation?
We target a BP goal of < 130/80 mmHg in line with KDIGO guidelines. (1)There are no RCTs or other high-quality evidence looking at BP targets in kidney transplant patients that compare outcomes, graft survival or mortality. One small RCT (ESCORT trial) in pediatric transplant recipients, comparing i...
What are your diagnostic and management approaches beyond statin therapy for hyperlipidemia in young adults with significantly elevated LDL levels in isolation (i.e. reasonable calcium score, normal lipoprotein A levels)?
It depends on other factors such as the presence of diabetes and a family history of early CAD. If either of these is present, I push hard with statins and possibly add Zetia to get the LDL down to 60-70. I also push for lifestyle changes such as moderate daily exercise, weight loss, and reducing li...