Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend vitamin C supplementation with PO iron in patients with iron deficiency?
Vitamin C supplementation is unnecessary. Taking the iron with a glass of orange juice away from food and especially coffee optimizes absorption. That being said vitamin C does no harm. See vonSiebenthal et al eClinical Works 2023 (Lancet publication), Benson et al, Lancet Haem 2025 or Auerbach et a...
How do you treat patients with Linear IgA that are deficient in G6PD?
Quite a unique clinical situation! One in which the diagnosis is rather rare, but with an added wrinkle where the most classic textbook therapy, dapsone, cannot be used.A few case reports have shown that omalizumab and dupilumab have been reported to effectively treat LABD: Almuhanna et al., PMID 37...
What is your preferred duration for triple therapy post-PCI in patients on systemic anticoagulation?
Most practitioners extrapolate data from the AUGUSTUS and PIONEER-AF trials to answer this question.These trial used apixaban and rivaroxaban, respectively, along with use of DAPT with clopidogrel 75mg qd and ASA 81mg qd. From these 2 trial, Augustus demonstrated lower bleeding risk compared to trip...
For isolated and very high lipoprotein (a) levels (LDL of > 140, has an Lp(a) > 100) in a patient with no cardiac symptoms or risk factors, would you start lipid lowering treatment, such as with a PCSK9i if they develop statin intolerance?
There are a number of trials going on for reduction of Lp(a) with both IM and PO meds. We know that lifestyle modification does not help for reduction of this very atherogenic protein. If calc scores are high, I would look into entering one of the trials. If the score is low (unlikely), I would wait...
How do you use baby tam, low dose tamoxifen, in your practice?
At SABCS 2022, we heard additional follow up results from Dr. DeCensi for TAM-01 (previous publication), which randomized patients with DCIS, LCIS, or atypia to low dose tamoxifen (5 mg daily) or placebo for 3 years. Similar to the prior full dose tamoxifen prevention trials, this resulted in about ...
What is your approach to treating patients with dupilumab induced facial redness?
Literature is quite clear that the majority of these patients have Malassezia hypersensitivity as the etiology and the pathophysiology is essentially the same as seborrheic dermatitis. The IL-4 blockade allows upregulation of Th17 activity, which is the inflammatory pathway for seborrheic dermatitis...
Do you treat prosthetic joint infections after a two-stage revision arthroplasty with oral antibiotics for the full duration of therapy, assuming a susceptible oral option is available?
This is a hard one-I definitely think the data is there for PO, but until the IDSA recommendations change and the culture of practice changes it is hard to make the switch to doing a full regimen PO! I also think the accountability of IV antibiotics is useful -with the visiting nurse, weekly labs, i...
How do you approach management of new onset ILD in a patient with RA who is otherwise well controlled on methotrexate or leflunomide?
We do not have any randomized controlled trials for DMARDs in RA-ILD. Most of the data is case series or retrospective analysis. Nonetheless, we can use current data to at least make clinical decisions until we receive more direction from high-quality clinical trials. We now know that in general met...
What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?
Unfortunately, there is no high quality data at this point to directly answer this question but here are some options. For patients who have only been treated with oral steroids, I would first consider the addition of weekly methotrexate at a dose of between 10 - 20 mg WEEKLY with supplemental folic...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...