Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the appropriate interval to obtain a hydroxychloroquine level after making a dosage adjustment?
Hydroxychloroquine has an initial whole-blood half-life of around 5 days, while its terminal half-life is around 40 days (Costedeau-Chalumeau et al., PMID 27745934). The former is relevant to evaluating whole blood levels after a dose change.This was confirmed in the PLUS study (see figure 2 in Cost...
What is your process for considering alternative imaging modalities for cardiac imaging when POCUS is limited by patient conditions, such as emphysema or body habitus?
When POCUS is limited, a multi-faceted process that considers the clinical question, patient characteristics, the strengths and limitations of available imaging techniques, and the available resources should be implemented. The most important question is what you are specifically trying to evaluate....
In a young male patient with hypogonadotropic hypogonadism and fertility goals, would starting testosterone replacement therapy affect fertility chances?
Men with hypogonadotropic hypogonadism due to congenital hypogonadotropic hypogonadism or acquired hypogonadotropic hypogonadism due to structural disease (e.g., a pituitary macroadenoma) typically require gonadotropin therapy to optimize spermatogenesis and fertility. For men who have hypogonadotro...
How do you counsel patients with non-statin associated inflammatory myopathies about statin use?
Patients with non-HMGCR-associated myositis could try statins, keeping in mind that they could develop statin-associated muscle symptoms (SAMS). Therefore, would start with fluvastatin/pravastatin/pitavastatin (that are less likely to cause SAMS) at a low dose and slowly escalate if there are no sid...
What medications have you had success with for patients with high functioning ASD and co-morbid ADHD and anxiety?
First, separating the problem and likely cause of the presenting symptoms or symptoms that you want to treat will be important for such patients. ASD kids will have stereotypic behaviors that may look like OCD or anxiety but may not be. Separating this is particularly important because regular presc...
Would you have a patient temporarily discontinue methotrexate while receiving a FAST or FAST FORWARD regimen for breast irradiation?
I favor continuing as the dose of MTX is low for RA and in CMF era with much higher methotrexate dose, RT plus MTX was well tolerated.
How do you manage withdrawal symptoms of SNRIs that exist even after slow taper?
Another strategy is to do a custom ultra-slow taper. You need to be able to trust the patient can follow through with the instructions. The venlafaxine XR capsule can be opened and sprinkled on food. You can decrease by very small amounts (<1 mg) by taking fewer and fewer beads over time (e.g., remo...
How do you cross-taper when switching from an SSRI to an SNRI?
It depends on which SSRI and SNRI are involved, as well as the dose of the SSRI. If switching from a low-dose SSRI, a cross-taper is not typically necessary given that both SSRIs and SNRIs increase serotonergic transmission and therefore a withdrawal effect will likely not be felt. If switching from...
How do you approach the timing of Rituximab during pregnancy in a patient with life or organ threatening autoimmune disease?
The short answer is that I give it whenever it is needed for organ or life-threatening disease. Giving it earlier in pregnancy may have less impact on the fetus/neonate. In general, we all try to avoid routine treatment with rituximab during pregnancy due to the expected placental transfer after the...
What is your approach to a patient with a low alkaline phosphatase?
This is a wonderful and increasingly relevant question as it is not uncommon for someone to have a low alkaline phosphatase and be told it is not important since alkaline phosphatase is only important if it is elevated. Causes for this abnormality include protein deficiency, Wilson’s disease, and hy...