Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What are your strategies for preventive migraine therapy in breastfeeding patients?
Transfer to milk depends on how highly a medication is protein-bound. Measurable concentrations occur for drugs <70% bound. >85% bound is not expected to have a measurable concentration in infants. Propranolol, amitriptyline, and Depakote are >90% protein-bound so I consider them first. Botox is not...
Which patient population would most benefit from inhaled insulin (Afrezza)?
Afrezza has the fastest onset of action and peak and shortest duration of action of any of the “ultra-rapid” prandial insulins. Its peak effect is 45 minutes vs 2 hours for the fastest injected insulin. Its duration of action is 2-3 hours vs 5-8 hours for injected mealtime insulins. A recent study s...
Any concern for lupus flare in patients undergoing laser hair removal?
Great question - no there is little concern for this because LHR wavelengths are not in the ultraviolet spectrum which is known to spark SLE flares. Even narrow-band UVB (phototherapy) has been used in SLE patients without much issue, however, this is controversial and some feel that depending on th...
What recommendations do you provide to patients with sensitive skin that can not tolerate retinoids more than a few times per week?
Our studies showed sensitive skin is mostly the result of a compromised stratum corneum. Microfissures provide channels allowing access to the underlying vulnerable epidermal epithelium. In the past, these patients were very difficult. Low doses of tretinoin partially encapsulated in microsponges we...
What treatments do you recommend and how do you counsel patients with postpartum hair loss?
I start with reassuring that it's fairly common to experience excessive hair shedding after pregnancy, about 3-6 months postpartum and usually peaking at about 4 months after giving birth. I counsel that many patients regain their normal hair growth over time, without any treatment. However, if they...
With the recent trials such as SELECT and STEP-HFpEF demonstrating benefits of GLP1-agonists in terms of CV risk reduction and improved exercise function, have you begun to incorporate this class of medications into routine CV health maintenance for patients with HFpEF and/or pre-existing CAD?
I would strongly support the use of this medication. The biggest challenge is insurance coverage. When would it be approved by insurance and how many hoops we will need to jump before they approve it?
What would be the differential and initial workup for tongue fasciculation?
Tongue atrophy and fasciculations, unless very severe and obvious, can be difficult to determine by clinical exam alone. I have had multiple patients who were told that they have ALS after an inexperienced examiner saw them for an initial visit and thought they had tongue fasciculations without furt...
Does the presence and location of cerebral microbleeds affect your decision for antithrombotic treatment in patients with atrial fibrillation?
That is a great question. Agree, the data is observational and no firm conclusions can be made. My practice is to consider left atrial appendage occlusion in patients with suspected CAA. In patients with hypertensive microbleeds, both resuming anticoagulation and left atrial appendage occlusion are ...
What recommendations do you provide to isotretinoin patients about delaying cosmetic procedures (lasers, fillers, botox) once they have reached their goal dose?
We basically perform any and laser procedures, even when patients are on isotretinoin if it is appropriate as far as the indication. We do tend to wait for 3 to 4 months for ablative fractional treatments, but all other treatments, such as hair removal, pigment removal, and vascular laser removal, a...
How do you approach palliative conversations about what patients can expect when deciding to stop maintenance dialysis?
I typically include this discussion with my patients as part of the discussion of what options are available to address irreversible progressive CKD (eGFR<25). I find it best to present all options for ESKD management in a balanced format and I open the clinic visits to all family and friends to sup...