Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you determine which patients with ANCA associated vasculitis may be good candidates for reduced dose glucocorticoid tapering?
This is an important question. Currently there are several groups of patients that benefit from reduced dose glucocorticoids: The largest group are patients who are receiving avacopan for remission induction. The ADVOCATE trial demonstrated that avacopan can markedly reduce the dose of glucocorticoi...
How do you read a PFT with restrictive type spirometry but normal lung volumes?
Non-specific pattern. Initially, NEJM papers showed that these patients develop obstructive patterns in the long term but follow-up papers have shown that patients can stay in that pattern (non-specific) or develop restrictive or obstructive patterns.
Does your evaluation of a young person with spontaneous upper extremity DVT vary as compared to lower extremity DVT?
The workup for a young adult with an upper extremity DVT differs for me in two ways: Venous thoracic outlet syndrome must be suspected and a careful history of repetitive overhead movements must be obtained. Consulting your vascular surgery team in these cases to ensure the anatomy does not put the...
For male patients who strongly prefer to stop anticoagulation for unprovoked VTE, are there any tools or labs that you would use to guide your decision making?
This is a challenging situation as one of the more useful tools to predict risk of recurrence after unprovoked VTE, the HERDOO2 rule, suggests that even with an otherwise "perfect" score, men have a high enough risk of recurrence to recommend ongoing anticoagulation. As such, and given the generally...
What is your approach to immunosuppression in patients with preserved kidney function who are found to have nephrotic syndrome of unknown etiology and cannot safely undergo a kidney biopsy?
This is a difficult scenario. Would definitely try to get a biopsy at a Higher level of care perhaps by Interventional Nephrology. Would obtain a comprehensive laboratory workup including kidney function, serum albumin level, random and 24-hour urine collection for albuminuria and proteinuria, Hepat...
Is there a role for dual antibiotic treatment with ethambutol and macrolide only, as opposed to three-drug antibiotic therapy, in the treatment of treatment-naive pulmonary MAC without cavitary disease?
That is a great question, as the role of rifampin (or rifabutin) regarding its relative contribution to the treatment of MAC is not overly clear. Historic data that is a few decades old raised the possibility of better activity when a rifamycin is combined with ethambutol (at least in vitro and furt...
Do you use delayed-release budesonide over prednisone or methylprednisolone for the treatment of IgA nephropathy, considering the available safety and efficacy data?
The two agents (TRF-budesonide and systemic glucocorticoids, the latter of which include prednisone and methylprednisolone) have never been compared head-to-head, and so direct comparisons are unavailable. I try to present both options to patients, and in particular, I will focus on the side effect ...
Are recurrent UTIs a contraindication to SGLT2i use?
I don't view UTIs as a contraindication to SGLT2i use, but I make a risk and benefit analysis with each patient. Bacterial UTI as well as mycotic vaginal infections may be a sign that the patient has excessive glycosuria from hyperglycemia. In general, treating hyperglycemia should lessen the freque...
Do you recommend discontinuing IVIG for a newly diagnosed HMGCR+ statin induced necrotizing myopathy who developed a recent brachial DVT?
Really, the issue is if the DVT was provoked or not. If possibly not provoked then would decrease the dose of IVIG or give it over a long time frame. For example, if the patient is on 2 gm/kg over 2 days, I would do 2 gm/kg over 4 days. Or reduce the dose to 1 gm/kg over 2 days.
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...