Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage recurrent urticarial lesions in a patient with underlying connective tissue disease that is otherwise well-controlled?
Similar to other cases of chronic urticaria - skin-directed therapy with TCS + high dose daily antihistamines (e.g. fexofenadine 180 mg bid + doxepin 10 mg qhs). Then in recalcitrant cases, you can use urticaria drugs (can go for dapsone, MTX or MMF if you want to also target underlying CTD or can g...
How do you counsel patients on the risks versus benefits of JAK inhibitors for the treatment of alopecia?
Because alopecia areata is a chronic condition that often occurs in healthy patients, risks of immunosuppressant medications need to be considered. Safety comparisons must be individualized based on the limited data available. Medications such as JAK inhibitors, which can yield immediate results, ma...
For patients with nephrolithiasis and hypercalciuria attributed to a parathyroid adenoma, how long after a partial parathyroidectomy do you assess for improvement in 24-hour urine calcium levels?
An interesting question! The physiology of parathyroid hormone is to reabsorb urinary calcium; that is why most patients with primary hyperparathyroidism are hypercalcemic! The better question is why are they hypercalciuric? I think the best answer has to do with the filtered load of calcium exceedi...
Is monitoring for fetal heart block recommended in pregnant patients with only slightly elevated SSA?
At this time, we don't have a consensus on the titer that causes heart block and how that changes across different labs. Dr. Buyon's group did present this at ACR. So I would recommend HCQ and monitoring for this patient.
How do you utilize JAK inhibitors in combination with other therapies to manage alopecia?
In general, JAK inhibitors can be considered a first-line treatment for many patients with severe alopecia areata, so they are often the primary treatment that I use for this condition. In almost all patients, however, I also add oral minoxidil to the treatment regimen (depending on the person, typi...
What are some measures to prevent flares of loin pain-hematuria syndrome?
Loin pain hematuria syndrome is a difficult problem because there are multiple potential causes that require individual solutions. For example, nutcracker syndrome requires decompression of the left renal vein. Recurrent kidney stones require the expertise of a urologist skilled in ureteroscopic or ...
What is your approach to the management of symptomatic Cystic Fibrosis carriers?
It depends on what symptomatic means. If they have symptoms of bronchiectasis, I treat them as bronchiectasis patients with airway clearance, antibiotics, hypertonic saline, etc. If they have one mutation, I will also make sure they get full gene sequence and also do sweat testing (if available nasa...
What is your approach to treating genital lichen sclerosus that is not responding to super-potent topical steroids?
Biopsy is the next step if it was never done to rule out SCC or another alternative process since clobetasol typically works in these cases. Traditionally, methotrexate has been a standard treatment. However, more recently, I've started using Rinvoq off-label with great efficacy.
Which medications do you recommend for lactating mothers with kidney disease and proteinuria that persists post-delivery?
I use ACE inhibitors, including enalapril and lisinopril, in the lactating mothers with proteinuria and hypertension. Captopril is also safe, but as it is dosed multiple times per day, I avoid this. There is no data on ARBs. If they are still recovering from an AKI or there is another issue, like hy...
Aside from lifestyle measures such as calcium intake, vitamin D repletion, and weight-bearing exercises and ruling out all secondary causes, what is the preferred approach to managing osteoporosis in young women with Z score of less than -2.5 and planning to get pregnant soon?
It is very helpful to have some knowledge as to the reason for the Z score of <2.5. Young women with low BMI can have a low Z score just due to the unloading of the skeleton. Increasing body weight can often improve BMD in these women. Presumably, she has a normal menstrual cycle. If not, the instit...