Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Can you explain the block and replace approach in the treatment of thyrotoxicosis, including when it is most appropriate to use and how it compares to other treatment options?
More than 20 years ago, Japanese researchers had data that suggest that remission rates for Graves' disease was much better with the block and replacement treatment with Methimazole/carbimazole and Levothyroxine. At least 3 US and European studies did NOT confirm this observation. I do occasionally ...
What is your approach to work up for patients referred for early onset osteoarthritis?
Great question and one that comes up fairly often. I created a mnemonic for causes of "secondary osteoarthritis" & these etiologies drive the workup - this might be appropriate for a person with OA in an unusual place or who is unusually young for having it. Here it is: THE CHARMING T- trauma H - ...
Do you avoid hyaluronic acid injections in patients with chondrocalcinosis on imaging?
The association between viscosupplementation and CPPD flares is reported but not truly well studied. There is a nice case series by Bernardeau et al., PMID 11302877 entitled “Acute arthritis after intra-articular hyaluronate injection: onset of effusions without crystals” in Ann Rheum Dis 2001;60:51...
What is your approach to treating patients with melasma that does not respond to hydroquinone-based topical therapies?
This is my Melasma algorithm: Hydroquinone triple cream qhs x 6 months + azelaic acid in the AM + tinted sunscreen Consider PO TXA (half of 650 mg tab bid), polypodium leucotomos bid (heliocare) Maintenance: stop hydroquinone and switch to compounded TXA/kojic/tretinoin combo cream qhs + vitamin C/...
What topical and oral therapies do you prescribe for patients with recalcitrant melasma?
This is my Melasma algorithm: Hydroquinone triple cream qhs x 6 months + azelaic acid in the AM + tinted sunscreen Consider PO TXA (half of 650 mg tab bid), polypodium leucotomos bid (heliocare) Maintenance: stop hydroquinone and switch to compounded TXA/kojic/tretinoin combo cream qhs + vitamin C/...
What is the next step in management of a thyroid nodule that was biopsied and classified as Bethesda III, but Afirma genetic testing reveals parathyroid signature?
This is not an uncommon clinical presentation of intrathyroidal parathyroid adenomas, diagnosed incidentally on molecular profiling of cytological indeterminate nodules (CIN). These adenomas most often have the imaging features of a TIRADS 4 thyroid nodule (with well-demarcated margins, solid, profo...
How do you approach the use of GLP-1 receptor agonists for the management of patients with metabolically healthy obesity?
I want to define my understanding of the term “metabolically healthy obesity”. Generally, this is meant to describe patients with a BMI in the obese range but without hypertension, dysglycemia or dyslipidemia. Obesity is associated with a wide range of medical conditions beyond those three such as o...
Do you recommend the use of Korlym (Mifepristone) for patients with difficult to control diabetes and evidence of mild endogenous hypercortisolism of unknown source?
This is an ongoing question - stimulated by the CATALYST study. The impetus for the study is the observation that many persons with uncontrolled Type 2 DM will fail an overnight 1-mg dexamethasone suppression test (~25%). Subjects with ACTH-dependent hypercortisolism were excluded from further study...
Are there situations in which you treat calcinosis cutis that is not symptomatic for the patient?
There is NO treatment for either the prevention of calcinosis or the dissolution of calcinosis. Every 5-10 years over the past 40 years there have been potential treatments but none have been confirmed. I do not use anything specific for the asymptomatic patient. I do rarely recommend surgery by an ...
How would you approach management of a patient with rapidly progressive systemic sclerosis with worsening skin disease, myositis, arthritis, dysphagia and failure to thrive developing within 6 months?
This is a unique subset of patients with very aggressive disease and high risk for poor outcomes with myopathy, poor GI dysmotility, at risk for early PH. We tend to treat them aggressively. I would consider rapid escalation of immunosuppression such as MMF and consider IVIG up front as well, especi...