Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For hypothyroid patients on dual replacement therapy (levothyroxine & liothyronine), do you recommend monitoring TSH while holding off on the morning T3 dose?
No, I do not withhold the morning dose of T3. Older studies have shown no effect of an oral dose of T3 on serum TSH levels (Saberi & Utiger, PMID 4422006).
What further evaluation do you pursue for patients who present with vague symptoms such as subjective fevers or intermittent night sweats, who have no pulmonary symptoms but have a positive IGRA?
Great question. Another scenario that is not uncommon is some degree of cough, sometimes for long periods of time, but no other symptoms. If their risk is higher for progression to active disease (e.g., immunocompromised; recent contact with an active case) I may do more than if the risk is low. My ...
How do you prescribe a steroid taper for radiation and checkpoint inhibitor related pneumonitis?
I subscribe to the philosophy of "hitting hard, tapering slowly" for cases of pneumonitis, either radiation pneumonitis, or checkpoint inhibitor-related pneumonitis (some of those cases probably have mixed origin, with contributions from radiation and/or checkpoint inhibitors). For severely symptoma...
Do you avoid use of inhalers with milk protein in patients with a milk allergy?
According to the Advair Diskus package insert, “Immediate hypersensitivity reactions may occur after administration of ADVAIR DISKUS, as demonstrated by cases of urticaria, angioedema, rash, and bronchospasm. There have been reports of anaphylactic reactions in patients with severe milk protein alle...
Do you prescribe fluocinolone in peanut oil in patients with peanut allergies?
Yes. Paller et al., PMID 12664021
Do you treat non-albicans strains of Candida on sputum culture or BAL in patients who are immunosuppressed?
I agree with these answers and do not treat either without biopsy.
How do you approach balancing the treatment of urinary incontinence with anticholinergic medications with the use of cholinesterase inhibitors in dementia?
This is a great question and speaks to the importance of shared decision-making and understanding the context of individual patients. Ultimately, it would be best to avoid anticholinergic medications in our patients living with dementia. Medications with anticholinergic properties increase the risk ...
What other considerations for hyperlipidemia management would you have for a patient with multiple prior PCIs whose LDL remains above goal on high intensity statin, ezetimibe, and evolocumab, assuming the patient is compliant with medications?
There are a few options, most of which depend on insurance coverage and patient preferences. But first, would do a chart biopsy to assess the efficacy of each of the therapies to better understand the reason for persistent LDL elevation. Perhaps they have a dysfunctional LDL receptor, so upregulatio...
How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?
Finerenone could replace spironolactone or eplerenone since the likelihood of adverse effects are less. Unfortunately, RCTs of finerenone have compared it placebo. Until superiority to spironolactone (a cheap and very effective drug for heart failure) is shown we cannot justify the cost.
Outside of their use in performance anxiety, have you tried or found benefit with a daily beta blocker for generalized anxiety?
In concert with a psychiatrist, I've used beta blockers for patients with a history of trauma and/or somatoform disorder to reduce sympathetic stimulation and bodily sensations that worsen anxiety. In one particularly challenging case, the near-immediate relief after taking propranolol was helpful i...