Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you discontinue anticoagulation in patients with antiphospholipid antibody syndrome, who have a remote history of thrombotic events and are now negative for pathogenic antiphospholipid antibodies?
I would certainly consider stopping anticoagulation in selected patients after an in-depth discussion about potential risks and benefits. I would not consider stopping AC in patients with a history of recurrent events, arterial events, or multiple risk factors for thrombosis (e.g. nephrotic syndrome...
What is your preferred approach to a pregnant patient in status migrainosus refractory to first line treatments?
I bring these patients in for occipital nerve blocks with only 2% Lidocaine. This is safe in pregnancy and has a high rate of success.
How do you manage patients with suspected chronic contact dermatitis and negative patch testing?
The management is the same as for any other eczematous dermatitis. Topical steroids, methotrexate or dupilumab for severe cases. The real question is do you have the correct diagnosis and if so, are you missing a rare allergen?
Would you recommend medical therapy for asymptomatic idiopathic intracranial hypertension with completely normal visual field testing?
If this patient has asymptomatic papilledema from idiopathic intracranial hypertension, then I might focus on weight loss first, which can be curative. I would follow her visual fields closely, however, and would have a low threshold to start acetazolamide if any change in her visual fields is noted...
How do you approach treating patients with erythema nodosum recalcitrant to NSAIDs?
Work up for the cause of ENodosum to determine if there is a trigger:TB, sarcoidosis, cocci/crypto/histo/blasto, Hodgkin's. ASO, dental abscess, Crohn's, ulcerative colitis, OCPs to name a few. SPEP possibly and or quant IGA with free light chains, just to name a few. Assuming all this is, you can d...
When and how do you initiate therapeutic phlebotomy for patients with hereditary hemochromatosis without evidence of end-organ injury?
Since the management of asymptomatic HH is seamless, if a patient's iron parameters are reflective of iron overload and there is zero evidence of end-organ damage, I recommend that they become blood donors, starting with every 56 days. I monitor on a regular basis to try to get them closer to low no...
What are your recommendations for a male patient who was recently started on imatinib and wants to conceive?
Great question. This comes up often. For males, they can continue to take their CML TKI and conceive a child. Of course, this is much more complicated for women as they should not be pregnant while taking a TKI. I would say that if the patient is having difficulties conceiving, he should undergo a ...
How do you counsel patients regarding the cardiovascular and cancer risks associated with tofacitinib?
In my experience, trying to discuss incidence rates and hazard ratios with patients is usually met with a response such as, “So what does this mean for me?” Translating the incidence rates into the number needed to harm (NNH) provides objective numbers which are easier for them to understand. Treati...
Do you still plan to offer tofacitinib to RA patients over 65 if they have one or more additional CV risk factors?
I would consider offering tofacitinib (or another JAK inhibitor) to patients over 65 with an additional CV risk factor, but only as a last resort after all other options have been exhausted.
Do you de-escalate airway clearance therapies in patients with CF who experience an improvement in mucus production and clearance after CFTR modulator therapy is started?
De-escalation of airway clearance therapy, and even mucolytic therapy, is a frequently encountered question since the introduction of highly effective modulator therapy. Since the majority of patients no longer have cough or sputum production, the necessity of such therapy is often questioned and it...