Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
At what point would you consider anticoagulation in a pregnant patient with lupus nephritis and non-nephrotic range proteinuria?
If the patient does not have APS and does not have nephrotic range proteinuria, then the indication for presumptive anti-coagulation is unclear.
What is the maximum diuretic regimen recommended in patients with end-stage kidney disease who have residual renal function and volume overload?
Studies in peritoneal dialysis have shown both the safety and benefit of high-dose furosemide. One study randomly assigned 61 incident CAPD patients to either furosemide 250 mg every day or no furosemide at the time of CAPD training and they were followed prospectively. Baseline 24-hour urine volume...
How do you counsel male patients with Androgenetic Alopecia who are trying to conceive about using dutasteride or finasteride?
I advise against dutasteride for those trying to conceive or who might have unprotected intercourse with pregnant women since dutasteride is in the semen. For 5 alpha-reductase inhibitors in general, the effects on sperm count and sperm motility are very well characterized. There is a reduction in s...
How do you approach treatment of RA with methotrexate in a patient with treated Hepatitis C and normal liver function?
Active hepatitis C infection can be present in the setting of normal liver function tests. So, I always check for the viral load, especially if the hep C treatment was done more than a few years ago. Here, the old alpha interferon-based treatments achieved a cure rate no better than 30%. The newer a...
How do you approach DMARD therapy in patients with rheumatoid arthritis and chronic hepatitis B?
Patients with hepatitis B core positivity, surface antigen positivity, and positive PCR for viral DNA, should be treated with entecavir prior to starting any DMARD. Given the DNA PCR is positive too, that indicates active viral replication and they may need treatment for a while before starting anyt...
How do you counsel patients on the use of topical nitroglycerin for Raynaud's?
I am actually not a big fan of topical NTG for Raynaud phenomenon. We know that there is some significant systemic absorption and patients may have high rates of side effects (such as headache). These rates were as high as 30% in some of the studies, which I think is higher than we see with use of o...
What are high-risk clinical and echocardiographic features in pregnant patients with congenital heart disease?
The most commonly used risk stratification tool available has been the mWHO maternal cardiovascular risk classification which places women into different categories (I-IV) based on diagnosis/ residual lesions. Class IV patients are considered very high risk for cardiovascular events (bleeding, throm...
How have you incorporated biologics targeting the IL-36 pathway (e.g. Spevigo) into your treatment algorithm for psoriasis?
I would use Spevigo for generalized pustular psoriasis. For more common forms of psoriasis, I prescribe biologics approved for plaque-type psoriasis.
Is there any evidence regarding bone density gains/fracture reduction in the setting of treatment with romosozumab after a two year course of teriparatide?
There was a study by Ebina et al., PMID 34020048 titled "To investigate the effects of prior treatment and determine the predictors of a 12-month treatment response of romosozumab (ROMO) in 148 patients with postmenopausal osteoporosis".This study was a prospective, observational, and multicenter st...
What do you recommend for women on AI therapy who experience excessive hair loss?
In addition to the suggestions from @Dr. First Last, there was also a study reported in 2018 by Freites-Martinez et al. in JAMA Dermatology that reported a moderate to significant improvement in endocrine therapy-induced alopecia with topical minoxidil 5%. This is a relatively straightforward, over ...