Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the therapeutic role and blood glucose lowering capability of bromocriptine and cholestyramine for the treatment of Type 2 diabetes?
In the 15 or so years since bromocriptine and cholestyramine were approved for the treatment of hyperglycemia in T2DM, I have never prescribed them for this indication. I also have very rarely used other FDA-approved glucose-lowering agents including meglitinides, alpha-glucosidase inhibitors and am...
How do you manage insomnia in cancer patients that is refractory to traditional sleep aides?
Insomnia and other sleep disturbances are very common in individuals diagnosed with cancer, and it is often helpful for patients to hear this. A good history of other contributors to sleep disturbance can be helpful as well. Often, depression, anxiety, and pain, as well as other stimulant medication...
What is your approach to managing sclerosing mesenteritis (mesenteric panniculitis)?
I have seen and followed dozens of patients with this diagnosis. As noted above, it is important foremost to be sure of the diagnosis. Mesenteric panniculitis can be part of the IgG4 associated spectrum and so a biopsy is useful if it can be done safely. The other disease in the differential is carc...
What initial workup do you perform when there is a concern for porphyria?
This is a terrific question. But a broad question. Porphyria refers to a defect in heme biosynthesis leading to the accumulation of porphyrins and porphyrin precursors. We should remember that there are three general categories of porphyria based on clinical manifestations: acute hepatic porphyria (...
How do you monitor patients with incidentally found high titer anti-smooth muscle antibodies without stigmata of liver disease?
I have quite a few SLE patients with ASMA who do not have any signs of hepatic disease (though I did not do bxs in those with normal hepatic transaminases). They are very common in the general population. I have down in my notes a prevalence of 16%. However, there are studies showing prevalences as...
What treatments have you found most effective for cholestatic pruritus?
My experience is mainly in Sjogren's or Sjogren's with PBC, ursodiol has been effective. Occasionally, I have used hydroxyzine or H1+H2 blockers. In Sjogren's where the skin biopsy has shown significant lymphocytic infiltration, mycophenolate or a calcineurin inhibitor trial has lead to the resoluti...
How do you approach the treatment of microscopic colitis?
If there is a temporal association between starting a drug like NSAIDs, PPI, SSRI, statin in the onset of diarrhea deny would stop the medication before beginning pharmacological therapy for microscopic colitis. If there is no potential drug trigger, and I stratify my treatment based on severity of ...
What is the anticoagulation recommendation for a chronic DVT?
Simply having a chronic DVT is not an indication for anticoagulation. In general, acute provoked VTE requires a minimum of 3 months of anticoagulation. For an unprovoked VTE, there are scoring systems that guide towards limited duration vs long-term of anticoagulation. So it depends on where the fin...
What is your target or goal lipoprotein (a) level for patients on PCSK9 inhibitors for either primary or secondary prevention?
Let me compliment the clinician who submitted the question because he/she measured lipoprotein (a) [Lp(a)] in the first place. Lp(a) was first described in 1964, but its contribution to atherosclerotic vascular disease risk has only recently attracted widespread attention. Part of that attention is ...
How do you address/manage the recreational use of dextromethorphan (sometimes called "robo-tripping") that has risen to the level of use disorder?
This problem of "robo-tripping" has become an increasingly observed clinical issue, namely the misuse of dextromethorphan with cough medication (Robitussin). This is often in conjunction with alcohol misuse. We recently published a case report in The American Journal of Drug and Alcohol Abuse (Ledwo...