Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should you consider thromboprophylaxis, even for low-dose lenalidomide maintenance, post-autologous transplantation?
In the event there are no adverse contraindications for the use of thromboprophylaxis, yes, I recommend the use of a minimum of 81 mg of aspirin daily with a low dose of lenalidomide. In this meta-analysis (Chakraborty et al., PMID 31913498), the risk of venous thromboembolism was low with a low dos...
What is your approach to tapering therapy in patients with pulmonary sarcoidosis who are asymptomatic with stable pulmonary function and imaging?
We generally do not use weight-based dosing for treating sarcoidosis but often will use 20 mg daily (0.25 mg/kg) as a starting point. If a patient is newly started on prednisone, then we may use a gradual taper 20 mg daily for 1 month, then 15 mg daily for 1 month, then 10 mg daily until they are re...
What postural change in FVC is suggestive of respiratory muscle weakness?
In our practice, an assisted ventilation clinic which is enriched with patients who have diagnosed neuromuscular disease and/or chronic respiratory failure of unclear etiology, we often use 12% or 200cc simply by analogy to the criteria we use to assess bronchodilator responsiveness during PFTs. Alt...
Do you recommend a particular antiresorptive/anabolic agent for patients who are at high risk for fractures but have high risk of osteonecrosis of the jaw?
Teriparatide has improved bone healing in patients with osteonecrosis of the jaw, so would be a good choice for patients at high risk of ONJ.
Is a daily prophylactic dose of aspirin appropriate for patients with coronary artery calcification by Chest CT or an elevated calcium score?
There are no good studies directly answering this question. However, most studies that have looked at statin use in patients with elevated coronary calcium scores have found that many of those patients are also on aspirin 81 mg daily. My own practice is that I would certainly use a statin in patient...
What is your approach to management of intradialytic hypotension and autonomic dysfunction in a patient with ESKD?
Decreasing dialysate temperature to 35.5 to 36 degrees has, in my experience, caused a marked decrease in intradialytic hypotension. We use midodrine in some instances. The decreased dialysate temperature is systemwide in all cases in our units.
What are your practice recommendations regarding live vaccinations in infants/children of women who are currently on DMARDs and are breastfeeding?
This question needs some clarification to provide an exact answer. However, in regards to DMARDs in lactation, per the ACR 2020 Reproductive Health Guidelines and resources like LactMed and Mother to Baby (both free!), Methotrexate, Leflunomide, and Mycophenolate are not recommended in lactation. Th...
What is a reasonable length of time for systemic anticoagulation in patients presenting with MI in the setting of coronary artery aneurysm with large thrombus formation?
This is a great question. I would make the following points in reply: The present standard of care for antithrombotic therapy after a type 1 acute myocardial infarction, with coronary thrombosis, is dual antiplatelet therapy for one year (preferentially including a potent P2Y12 inhibitor). Current e...
Is GLP-1 therapy a viable treatment option for a patient with Type 2 Diabetes complicated by atherosclerotic heart disease and cholelithiasis?
The absolute risk difference between GLP1RAs and placebo was not remarkable (5 -27/10,000 per year for different conditions such as biliary disease, cholelithiasis, cholecystitis, cholecystectomy and biliary cancer). In addition, the risk of pancreatitis was not higher (RR 1.46 [0.59 to 3.61], P val...
How do you workup splenomegaly related to possible hematologic etiology in the absence of abnormal blood counts, adenopathy or severe constitutional symptoms?
The presence of splenomegaly is an important finding found either on physical exams or by imaging. As noted in the question, the initial work up includes physical exam looking for lymphadenopathy. In addition, laboratory evaluation, including absolute white count, and differential may help explain w...