Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach osteoporosis management in a patient who fractures while on denosumab therapy?
This is a scenario that we run into at times and is very difficult with data suggesting a decline in BMD after discontinuation of denosumab as well as data from DATA-Switch trial from 2015 revealed that switching from denosumab to teriparatide resulted in progressive or transient bone loss. I would ...
How do you manage a patient with superficial venous thrombosis with close proximity (<3 cm) to deep veins and an inherited thrombophilia ?
I would treat the patient for 3 months with a DOAC and then repeat the scan. If the clot is resolved, I would order a d-dimer and Factor VIII level on anticoagulation. If the tests are negative, I would stop the DOAC and retest at 30, 90, and 180 days. If tests remain negative then stay off anticoag...
Given the "LDL Paradox", in which RA patients with the highest levels of inflammation can have ultra-low levels of LDL (<70), how do you approach initiation of statin therapy in these patients?
Evaluate lipids at the time of remission/low disease activity and if elevated and the patient is a good candidate for statin therapy, initiate a statin using criteria for the general population.
Would you consider use of an oral bisphosphonate (such as alendronate liquid) in a patient with eosinophilic esophagitis?
My general approach to patients with any form of esophagitis for whom bisphosphonate therapy is indicated is to treat with zoledronate. I am not aware of any data that has reviewed the use of a liquid form of a bisphosphonate for patients with esophageal disorders including eosinophilic esophagitis,...
How do you evaluate and treat patients with suspected POTS?
POTS is diagnosed based on increased heart rate of more than 30 beats per minute in adults and more than 40 beats per minute in adolescents with no major drop in blood pressure from supine to standing or after tilt table from supine to 70 degrees upright. Many patients have POTS as an isolated cond...
Is it ever appropriate to reduce urate lowering therapy dose due to very low urate levels?
In my opinion, there are no known adverse outcomes related to very low serum urate levels. Suspected, but not proven, associations of dementia with sustained hypouricemia, have been used to create an impression that there may be one benefit of avoiding hypouricemia. There are multiple reasons for no...
How long after completion of radiation therapy should patients continue fluoride treatment for dental health?
Indefinitely
How often do you order imaging to assess for possible degenerative joint disease in the spine in patients with neuropathic itch?
Only if the itch is localized, mainly unilateral like in notalgia paresthetica of the back or the forearm.
What is your approach to treating patients with chronic pruritus of unclear etiology?
After a thorough workup (which includes some or all of the tests below) I typically follow a treatment algorithm for Chronic Pruritus of Unknown Origin or CPUO. This includes empiric ivermectin or permethrin to rule out atypical scabetic itch (this has fooled even the most astute clinicians), topica...
How do you approach restarting biologics for psoriasis patients who have discontinued therapy for 3-6 months?
For patients that have missed just a couple of months, I just restart the maintenance dose. If they have been off the medication for 6 months or more, I prefer to start with a loading dose again.