Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there a risk of increased skin toxicity with combined radiation and doxycycline?
No reports that I am aware of. Tetracyclines have an absorption wavelength of ~300-350 nm and can be pushed into an excited energy state by primarily UVA (320-400 nm) waves. Relaxation back to base state leads to chemical reactions that generate photoproducts that serve as antigens in a cutaneous al...
How has the recently FDA-approved topical cantharidin altered your molluscum treatment algorithm?
I recommend the use of topical cantharidin on a limited number of lesions, since the blistering can be painful especially in young children. Moreover, by treating a few lesions you may trigger an immunologic reaction that results in spontaneous resolution of untreated lesions as well. Moreover, we p...
What is your approach to managing osteoporosis in patients with end stage kidney disease?
I don't believe you can make a diagnosis of osteoporosis in patients with ESRD. They have to be treated based on the disorders associated with CKD-MBD and not solely based on the results of a bone density scan. In some patients with documented low turnover disease and mineralization defect, some may...
When do you consider stopping anti-seizure medications in seizure-free pediatric epilepsy patients?
Prior to 1988, we would never dare take a patient off seizure medicine if the patient was seizure-free.Callaghan's paper published in the New England Journal of Medicine (Callaghan et al., PMID 3127710) clearly showed that patients who were seizure-free on Tegretol for 3 years had a 90% chance of be...
Would you expect cinacalcet to lower calcium levels in a patient with Familial Hypocalciuric Hypercalcemia (FHH)?
The hypercalcemia in FHH is not primarily driven by overactive PTH secretion, so targeting the CaSR pharmacologically would not address the underlying pathophysiology. However, I suppose inducing hypoparathyroidism with Cinacalcet would induce calciuria, though at the expense of hypocalcemia.
Do you recommend adjusting the duration of a drug holiday based on the specific bisphosphonate used when treating osteoporosis?
If there has been a satisfactory response, the drug holiday for alendronate can be 2 years while zoledronic acid, which is more tightly bound to bone, can be stopped for three years.
What are reasonable alternatives to invasive angiography for CAV surveillance in patients who are a few years out from cardiac transplant with impaired renal function?
In our practice, we move to PET-CT on Year 3 if the prior 2 angiograms with IVUS did not show accelerating disease. The issue with CAV is that there is not much to do about it reactively. The best you can do, is switch to an mTORi regimen early and optimize lipids. IVUS is useful for that reason. Be...
How do you manage nephrotic range proteinuria in a pregnant patient with a known history of diabetic nephropathy prior to pregnancy?
Interesting question. Part of this depends on what one thinks of the etiology of the nephrotic syndrome. With a history of diabetic nephropathy, the odds are this is a continuation/natural worsening of the underlying diabetes, and hence there is no specific therapy exists. Hence, a renal biopsy woul...
Do patients with central adrenal insufficiency on maintenance hydrocortisone therapy require doubling of their corticosteroid during chemotherapy cycles?
I would follow the same sick day rules. If the patient is not feeling well with nausea, diarrhea, or worsening fatigue, the same rules of doubling the GC dose would apply. In cases of severe vomiting and not being able to keep the double dose of GC, parenteral GC injection and going to the ED for fl...
How long should patients with atrial fibrillation who are already on systemic anticoagulation and are status post TAVR and PCI 6 months ago remain on Plavix?
If PCI was done for a plaque rupture event I.e. ACS, then DOAC + plavix for a year is the current SOC. For non ACS PCI, DOAC + plavix for 6 months, followed by DOAC mono Rx is a reasonable option.