Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to treatment of skin-limited cryoglobulinemic vasculitis in patients with Sjogren's syndrome who lack evidence of neurological or renal involvement?
I have given this patient Rituximab prior with success.
Would you give transdermal hormone replacement therapy to a woman with remote history of provoked pulmonary embolism?
There is good evidence that transdermal HRT does not pose the same risks as oral HRT (Morris and Talaulikar, PMID 36573625). ASA or DOAC prophylaxis is likely not indicated.
Do you recommend patients continue folic acid for a few weeks after methotrexate discontinuation?
If Methotrexate (MTX) is being discontinued due to a side effect or toxicity, it make senses to maintain the folic acid supplementation for an additional few weeks as this may help minimize some of the unwanted symptoms such as mouth sores or nausea. If MTX is being discontinued due to lack of effic...
What is your approach to patients with positive anti-CCP, negative RF and tobacco use, but no current signs of active rheumatoid arthritis?
There is considerable evidence supporting a link between citrullination of proteins including the generation of CCP antibodies and smoking. A number of studies that have followed patients with this clinical phenotype have identified a heightened risk for the development of full-blown rheumatoid arth...
How do you define severe hypoxic burden on home sleep testing?
There seem to be two questions here. First, can you measure hypoxic burden on a home sleep test? The answer is that technically it can be done without great difficulty. However, as far as I know, there are no home sleep apnea testing devices that offer hypoxic burden as an outcome measure. Thus gett...
Do you ever taper or stop urate lowering therapy in patients who have had no gout flares and serum urate persistently below 6 mg/dl?
Part 1: Yes, but not often.Part 2: No, or extremely rarely. Read on. Urate lowering therapy (ULT) mobilizes monosodium urate (MSU) deposits and in time will resolve all of the clinical features of gout. The formation of these deposits results from sustained serum uric acid (SUA) elevations in excess...
How do you manage anticoagulation bridging for outpatient ESKD patients given concerns for bleeding risk with enoxaparin in this population?
I don't think we know what is the best route to take. Personally I still usually give lower doses of enoxaparin but it all depends on the circumstances. Why the patient needs anticoagulation? Does the risk of hospitalization out way the risk of increased bleeding from enoxaparin? Can the patient get...
How do you manage dry eye related to Pluvicto Lu-177?
This is a real but uncommon side effect of Pluvicto therapy. Per VISION, it will happen in maybe 3% of patients but almost never high grade. Interestingly, the absorbed dose for the lacrimal glands is 2.1 Gy/Gbq - which over 6 cycles full dose at 7.4 GBq/200 mCi per cycle means 92 Gy. There was a me...
When do you prescribe topical JAK inhibitors for adult patients with atopic dermatitis?
For adult patients with atopic dermatitis, I typically start with topical steroids with or without topical calcineurin inhibitors as maintenance therapy. If minimal improvement with topical steroids/calcineurin inhibitors, then I turn to other topicals including topical JAK inhibitors and/or crisabo...
When should I consider anticoagulation in an unprovoked upper extremity deep venous thrombosis?
Would do careful history like hunting Would do anticoagulation Age and fam hx may be helpful if one does thrombophilia workup