Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What abortive migraine treatment is preferred in pregnant patients?
Sumatriptan has a good safety record in pregnancy based on pregnancy registries and studies.
Would you recommend a CGRP inhibitor for migraine prevention in pregnant patients?
No, I would never recommend the use of a CGRP inhibitor during pregnancy (or for a woman breastfeeding for the matter). Currently, there exist five anti-CGRP preventative options with a sixth most likely to be FDA approved here shortly. Of the five currently approved CGRP inhibitors for migraine pre...
At what point could starting AEDs be considered for patients with recurrent simple febrile seizures?
Assuming this is a young child, it is a subtype of "provoked" seizures. It is reasonable to treat if they are frequent or severe. Any ASM will do. Wean off like any other ASM treatment: slowly and gradually. Febrile seizures should not occur after the age of 5 or so.
Should patients with cerebral amyloid angiopathy have any statin medications discontinued?
There is equipoise about use or discontinuation of statin in patients who have had an intraparenchymal hemorrhage attributed cerebral amyloid angiopathy. A multicenter clinical trial is investigating this question (https://clinicaltrials.gov/ct2/show/NCT03936361). I would base continuing vs disconti...
What is your threshold for number of alcoholic drinks per week before reconsidering prescribing methotrexate/leflunomide?
It's a great question, and the usual practice probably depends heavily on the culture in which one trained/practices. For example, the US and UK governmental guidance are notably different in their recommendations. This contrast in attitudes is also reflected in differences in the governmental defin...
How do you approach contraception and pregnancy counseling in women of childbearing age with Desmoid tumors who may be contemplating future pregnancy?
Sporadic desmoid tumors have a propensity (80% of cases) for women of childbearing age and they do seem to come up during and after pregnancy. Here are my thoughts on contraception and pregnancy for women with desmoid tumors.1. Norethindrone pill. This is not specific to people with desmoids. I am a...
Do you routinely check platelet counts after COVID-19 vaccines in patients with chronic ITP?
Yes. the side effects of COVID vaccines are still evolving. Mild to moderate thrombocytopenia was noted and severe thrombocytopenia is extremely rare. I would follow an abundance of caution and do weekly complete blood counts, especially in the ITP patient.
Is there a role for prednisolone over prednisone in rheumatic patients with hepatic impairment?
Yes. In general, prednisolone is preferred over prednisone in patients with significant liver disease as conversion of prednisone to its active form (prednisolone) may be impaired. The first citation below provides a great deal of information regarding the different steroid formulations.As an aside,...
How would you advise patients with known stable autoimmune thrombocytopenia regarding the Ad26.COV2.S (Johnson & Johnson/Janssen) vaccine?
For patients with autoimmune thrombocytopenia due to SLE, I favor avoiding vaccines that employ a viral vector due to concerns for viral induced lupus flare.For patients with thrombocytopenia in association with antiphospholipid antibodies, would avoid the Johnson & Johnson (as well as Astra-Zeneca)...
Do you routinely prescribe vaginal estrogen therapy post chemo/XRT for female patients finishing anal cancer treatment?
No. We encourage all female patients to use a vaginal dilator and Replens over the counter vaginal moisturizer (vitamin E, B, non-hormonal) after chemoradiation. We also encourage patients to see their gynecologist to discuss topical estrogen therapy. There are potential side effects/drug interacti...