Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to treatment for patients with microscopic polyangiitis who have sustained remission at 6 months after induction rituximab?
This is an excellent and challenging question. Most studies of AAV used at least 12 months of maintenance therapy (Pagnoux et al., PMID 19109574), with most using longer regimens (e.g. 22 months in MAINRITSAN [Guillevin et al., PMID 25372085]). Further, studies suggest that longer maintenance therap...
How do you assess potential fetal harm in patients who have unplanned pregnancy while taking teratogenic medications?
This is a helpful reference that includes a table that summarises the evidence and the prevalence of maternal and fetal complications for many teratogenic medications. Götestam Skorpen et al. PMID 26888948 “The EULAR points to consider for use of anti-rheumatic drugs before pregnancy, and during pre...
How frequently do you monitor LFTs and CBC after initiating endothelin receptor antagonists?
Endothelin-1 is a potent vasoconstrictor involved in vascular remodeling. There are three FDA-approved endothelin receptor antagonists (ERA) in the market for the treatment of pulmonary arterial hypertension (PAH), including bosentan, ambrisentan and macitentan. ERAs are used in PAH to improve exerc...
Do you counsel your RA patients to hold their methotrexate dose for simple infections such as UTIs?
I recommend that the default position is to hold methotrexate if currently exhibiting any signs or symptoms of infections. This includes asymptomatic as well as symptomatic simple UTI. Resumption of methotrexate can occur 1 week later if restored to good health with the clearing of sx. This emphasis...
Do you consider travel as a risk factor for DVTs in the absence of any other underlying predisposing factors?
Unfortunately, there are no strong guidelines around this topic. In general, I do not count long car rides as a risk factor unless there is something extremely unusual about the trip. Most people are going to get out and stretch their legs every couple of hours. Long flights are different. There are...
Do you change management in patients that are taking bisphosphonates and develop atrial fibrillation?
I allow bisphosphonates in patients with afib. In both the alendronate and zolendronic acid trials subanalysis revealed a minimal increase of afib but FDA review suggested both conditions occur often in the elderly and there was no causality. Our group has given several thousand infusions with no af...
What topical and oral therapies do you prescribe for patients with papulopustular rosacea?
Over the years, metronidazole cream/gel monotherapy has been less effective in the patients we see. Skin Medicinals has a triple rosacea cream with ivermectin/itraconazole/azeleic acid and has been quite effective as well as cheaper than getting all 3 separately. Doxycycline at doses between 40mg - ...
What interventions have you found most effective for reducing ED utilization in patients with PNES?
I have a frank discussion regarding the difference between epilepsy and PNES and the differing modes of treatment. I also refer them to our behavioral health department for cognitive behavioral therapy. That seems to decrease their ER visits.
In terms of contraception, what do you recommend for patients with a history of hormone receptor-negative compared to hormone receptor-positive breast cancer?
Avoid oral contraceptives. Prefer barrier contraception and IUD.
How long after starting an antiepileptic drug do you check levels?
Based on the half-life of AED and sometimes case-to-case based. General guidelines is 2-4 weeks of starting the AED.