Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How does the location or type of psoriasis affect your initial biologic choice?
Scalp and palmoplantar psoriasis are always tough. Inverse and nail psoriasis as well, but I don't find as much of a disconnect with inverse psoriasis (nb: it tends to be one of the "easier" to treat areas of psoriasis once you've made the diagnosis, evidenced by the rather stronger efficacy results...
What is your next step in management for patients who develop sexual side effects on an SSRI (anorgasmia, low libido, etc.) but are responding well to therapy?
Managing side effects from SSRI medications is a key component of treating patients in the outpatient setting who are suffering from depression and/or anxiety. This is doubly true given the fact that primary care is often the most accessible, and often most trusted, source for patients to make their...
How do you approach treatment change in patients with psoriasis who have been stable on an IL-17 or IL-23 agent but then begin to have breakthrough skin disease?
It really depends on where the patient is in their treatment journey. Patients who have tried and failed other biologics I try to optimize response by: increasing the biologic dosing frequency if insurance will allow, adding topicals, particularly newer ones like tapinarof or roflumilast, adding ph...
What is your experience managing patients with chronic spontaneous urticaria occurring only at night?
When I have patients with Chronic Spontaneous Urticaria (CSU) that is not responding like CSU should to medications, the first thing I wonder is if this is really CSU. In these situations, I will order additional lab work-up for CSU and conditions mimicking CSU, as discussed in a recent review in JA...
Do you recommend a waiting period to conceive after prostate radiation?
Yes, I typically advise that men and their partner use contraception for at least 3-4 months after the last fraction of radiotherapy based on the fact that the maturation cycle of sperm is estimated at approximately 2- 2.5 months. I typically counsel men prior to treatment that there is a chance (bu...
What parameters would you use to monitor and interpret iron levels in a hemochromatosis patient where ferritin is unreliable due to underlying chronic inflammation?
The biggest question in these situations is whether the patient truly has iron overload vs. just high ferritin. If iron sat is not elevated, true iron overload is very unlikely. If both ferritin and iron sat are elevated, but they don't have a homozygous C282Y genotype, I make sure that the patient ...
How do you assess and adjust treatment in patients who develops hypothyroidism after being on lithium for several years?
It depends on whether the patient is symptomatic. If not, careful monitoring is all that is needed. If there are significant symptoms, treatment with levothyroxine would be needed. Continued use of lithium is appropriate if it has been effective over time.
When discontinuing Denosumab after more than 2-3 years of therapy, when do you recommend giving the first dose of zoledronic acid?
My practice has been that after 2-3 years of denosumab, I wait 6 months and then start zoledronic acid.
What duration of antibiotic therapy do you use for a loculated parapneumonic effusion that does not meet criteria for empyema?
It would be great to see more prospective research in this area. I think we should be a bit more nuanced in our approach as it seems to be crude to recommend 4 to 6 weeks of IV antibiotics for every parapneumonic effusion or complicated pleural space. I think that in melding the IDSA and American As...
Do you routinely use cefdinir for the treatment of common infections diagnosed in the outpatient setting such as CAP, uncomplicated UTIs?
Not routinely. More expensive than equally effective alternatives.