Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How long do you monitor proteinuria after starting an SGLT-2 inhibitor before considering adding another medication if proteinuria is not at goal?
I would typically wait 2-3 months. Most such patients should be on RAAS blockade which should be maximized if tolerated first.
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
I would use DAPT for three months after the stroke. I do not see evidence for either anticoagulation or protracted DAPT for ICAD.
At what point should aspirin therapy for stable cardiovascular disease be discontinued in patients with a diagnosis of chronic cerebral microbleeds or possible Cerebral Amyloid Angiopathy?
I would continue low aspirin indefinitely.
How soon after an end stage kidney disease patient receives a MRI study with gadolinium contrast do you perform their next hemodialysis session?
Very contentious question. But as an author of the NKF and ARA position paper on this, I would follow our advice, no need to dialyze immediately after, but try to time the study with the next dialysis.Weinreb et al., PMID 33170103ASN Communities (for ASN members) had a VERY LONG post on this general...
What treatment options would you consider for a young patient with limited mobility, low bone mass and multiple vertebral compression fractures who is on dialysis for advanced kidney disease?
There are a lot of variables to this question. I would worry that the person may have a variant of OI (osteogenesis imperfecta) or some other collage problem and then add renal failure to the mix. I would try to establish the causes of each problem first such as steroid induced bone disease or a bon...
For patients with essential thrombocythemia already on prophylactic dose DOACs, do you defer starting aspirin?
I usually defer aspirin in these situations. There is evidence from PV that aspirin plus anticoagulation increases bleeding risk (Zwicker et al., PMID 34162181). If an ET patient has a high-risk disease with prior arterial thrombosis, then I would favor adding aspirin.
Do you routinely recommend doxycycline for pregnant individuals with rickettsial diseases despite the historical concern for side effects in pregnancy?
It has been known for years that short courses (<3 weeks) of doxycycline are safe in pregnancy and in young children. This article just reinforces the recommendations. Rickettsial diseases have significant morbidity and mortality and should be treated with the best (and best proven) antimicrobial. T...
How do you approach long term management of glucocorticoid-induced osteoporosis in patients who develop osteonecrosis of the jaw on antiresorptive agent?
Osteonecrosis of the jaw is a rare complication of anti-resorptives with the exception of high doses used for cancer patients. Teriparatide (TPTD) has been anecdotally reported to assist in healing of ONJ. The patient described remains on glucocorticoids and is at very high risk for fracture, especi...
Would you consider adding or switching to pirfenidone for a patient with progressing UIP (based on imaging and PFTs) who is currently on nintedanib?
Yes, I would consider it. There's some recent literature addressing this, which indicates switching may be associated with disease amelioration. Why might it work? Not super clear, perhaps biologic differences or maybe driven by better compliance. Smarter people than me could probably speak to the r...
Do you recommend bedtime administration of antihypertensives in patients who exhibit nondipping on ambulatory blood pressure monitoring?
Most of the effective anti-hypertensive medications are long-acting, with therapeutic levels maintained for up to 72 hours between doses. From a pharmacokinetic perspective, dosing these meds (like amlodipine and chlorthalidone) at night would not make a difference. Data supporting nocturnal dosing ...