Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend using anastrazole in men developing gynecomastia while on testosterone replacement treatment for hypogonadism depending on pre-treatment estradiol level?
There is no role for aromatase inhibitors (e.g., anastrozole) for the prevention of gynecomastia. A randomized trial of anastrozole for the treatment of gynecomastia demonstrated no benefit compared to placebo.There is no reason to administer prophylactic therapy prior to the initiation of testoster...
How would you approach chronic Achilles tendonitis that persists despite rest and physical therapy?
When situations like this arise, the first step is to re-evaluate the duration of symptoms and ensure the full trial of conservative management (rest, ice/heat, NSAID/Tylenol, PT) has been done. Oftentimes, it takes months to fully recover, even with these measures. If the symptoms persist despite a...
How would you approach chronic Achilles tendonitis that persists despite rest and physical therapy?
When situations like this arise, the first step is to re-evaluate the duration of symptoms and ensure the full trial of conservative management (rest, ice/heat, NSAID/Tylenol, PT) has been done. Oftentimes, it takes months to fully recover, even with these measures. If the symptoms persist despite a...
What factors would lead you to extend the duration of antithyroid drug therapy in a patient with Graves' disease who is clinically euthyroid at 12 months but has risk factors for recurrence?
One should never discontinue methimazole after an arbitrary period of time without checking anti-TSH receptor antibody levels. If they are positive or even “normal” but not undetectable, the patient will inevitably have a recurrence of their hyperthyroidism relatively quickly (Laurberg et al., PMID ...
What oral treatment options would you offer a patient with severe onychomycosis who is also on methotrexate for another condition?
I prefer pulsed terbinafine at 250 mg daily x1 week every other month. Dr. Zaias showed in a comparative study that pulsed terbinafine works as well as giving it daily for 3 months, and since the patient is only taking this for 1 week every other month, risks for hepatotoxicity are minimal.
Would you recommend giving N-acetylcysteine in addition to holding diuretics in a patient with chronic kidney disease and mild hypervolemia who is planned to have a contrast study?
There are several meta-analyses showing conflicting evidence on the use of N-acetylcysteine to prevent contrast-associated AKI. However, the largest randomized trial (PRESERVE) did not show any benefit from using oral N-acetylcysteine in 4993 high-risk patients undergoing scheduled angiography (Weis...
For hypothyroid patients on dual replacement therapy (levothyroxine & liothyronine), do you recommend monitoring TSH while holding off on the morning T3 dose?
No, I do not withhold the morning dose of T3. Older studies have shown no effect of an oral dose of T3 on serum TSH levels (Saberi & Utiger, PMID 4422006).
What further evaluation do you pursue for patients who present with vague symptoms such as subjective fevers or intermittent night sweats, who have no pulmonary symptoms but have a positive IGRA?
Great question. Another scenario that is not uncommon is some degree of cough, sometimes for long periods of time, but no other symptoms. If their risk is higher for progression to active disease (e.g., immunocompromised; recent contact with an active case) I may do more than if the risk is low. My ...
How do you prescribe a steroid taper for radiation and checkpoint inhibitor related pneumonitis?
I subscribe to the philosophy of "hitting hard, tapering slowly" for cases of pneumonitis, either radiation pneumonitis, or checkpoint inhibitor-related pneumonitis (some of those cases probably have mixed origin, with contributions from radiation and/or checkpoint inhibitors). For severely symptoma...
Do you avoid use of inhalers with milk protein in patients with a milk allergy?
According to the Advair Diskus package insert, “Immediate hypersensitivity reactions may occur after administration of ADVAIR DISKUS, as demonstrated by cases of urticaria, angioedema, rash, and bronchospasm. There have been reports of anaphylactic reactions in patients with severe milk protein alle...