Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage a provoked blood clot for a patient who had been placed on low dose DOAC for history of unprovoked blood clot?
To clarify the scenario: the patient had an unprovoked VTE for which they are currently on low dose DOAC and now have experienced recurrence in association with a well-defined (as outlined in ASH guidelines Ortel et al., PMID 33007077) provoking event. A number of additional variables would weigh in...
At what point, if at all, do you decrease the frequency of or discontinue pegloticase infusions after achieving persistently low serum urate levels?
This is one of the most frequent questions physicians have about pegloticase therapy. To review, the goal of pegloticase therapy is to manage the gout patient who has an overwhelming disease burden from deposits of MSU in joints, bone and soft tissues. Frequent flares, chronic synovitis, tophi inter...
Is close observation a reasonable option for elderly patients with a small basal cell carcinoma of the face?
Yes, depending on life expectancy, logistics, and morbidity of treatment which would be minimal with RT.
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS. I.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). * I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
How would you treat a woman with iron deficiency anemia, unresponsive to iron sulfate, and with allergic reaction to iron sucrose?
Needs more information. Is the issue unresponsiveness or intolerance? Frequently, patients report GI intolerance and don't really take it. It's crucial to inquire about this and consider trying different preparations to find a suitable option. What was the nature of the iron sucrose allergy? Sometim...
What oral therapies do you most commonly recommend for skin cancer prevention?
I don't use a lot of oral medications for this problem. The one I use most is Nicotinamide and I think the data is really only supported for SCCs, not BCC. In the past, I have used low-dose oral retinoids but this can be challenging depending on co-morbid conditions and lesions tended to spring up w...
How do you manage asymptomatic patients with incidental findings of the carotid web?
Terrific question. I would certainly not pursue interventional treatment in asymptomatic patients with carotid web. The role of aspirin is also debatable and not conclusively proven. I would ensure vascular risk factors are controlled and consider starting aspirin if otherwise indicated based on ove...
In an RA patient with positive RF and CCP abs who is stable on TNFi biologic, how would you approach incidentally found low titer positive DsDNA abs?
ANA and dsDNA antibodies can generally be overlooked in seropositive RA if one is planning to treat (or is treating) with TNF antagonists. There are rare instances of TNFi-induced lupus-like diseases but these are not predicted by pre-existing ANA or dsDNA antibodies.
Do you combine oral and topical NSAIDs for pain relief?
This is a challenging situation but a clinical scenario frequently faced by a practicing rheumatologist. Topical NSAIDs rarely achieve a measurable blood level, and frequently can provide good pain relief at the site of symptoms. It can be a useful way to reduce the milligram dose of an oral NSAID, ...
How do you manage pityriasis lichenoides chronica (PLC)?
If you are confident in the diagnosis of PLC, which isn't always easy to be, then no systemic workup is needed. The issue is the spectrum of disease and feeling confident you are truly dealing with PLC and not a related disorder with a possible risk of progression (LyP et al). Given that oftentimes ...