Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the minimum eGFR at which we should avoid initiating SGLT2i therapy?
The minimum eGFR to avoid initiating SGLT2i is different depending on the medication. Canagliflozin or Invokana is less than 30 ml/min. Dapagliflozin or Farxiga is less than 25 ml/min. Empagliflozin or Jardiance is less than 20 ml/min. With recent study suggests you still can continue the therapy wi...
When do you consider prescribing medications such as Aricept in patients with Down Syndrome who start having memory issues?
By age 60, there's a 60% chance that most people with Down syndrome will begin developing symptoms or signs of Alzheimer's disease. However, it’s important to also keep in mind that there are many other reasons why a person with Down syndrome may show signs of decline and it may not be Alzheimer's d...
When would you suspect metabolic myopathy and what is your approach to initial workup?
Great question and really important to rheumatology practice. As always, a history and physical exam is the best initial diagnostic tool. It’s a little bit difficult because of the sheer number and heterogeneity of non-autoimmune myopathies that clinicians may encounter, but a few general principles...
What is your goal ferritin level in pregnancy?
The goal is really to avoid iron deficiency and <30 best defines this state. Need to be wary of circumstances such as inflammation where the ferritin level may be falsely high even in the setting of reduced body iron.
Do you send CSF or serum ACE levels in the workup of neurosarcoidosis?
Unfortunately, serum and/or CSF ACE levels are just not sensitive or specific enough to guide the diagnosis or treatment of sarcoidosis, particularly neurosarcoid. Rather, imaging characteristics, specific organ system involvement, and biopsy results are much more useful in my practice.Bradshaw et a...
Would you increase or maintain the same initial dose of methimazole for treatment of hyperthyroidism if symptoms and thyroid tests improve but are not normalized?
Starting a hyperthyroid patient on the correct dose of methimazole (MMI) is of paramount importance. According to the 2015 ATA guidelines on the management of hyperthyroidism (Ross et al., PMID 27521067), the initial methimazole dose should be based on the patient's serum free T4 level: Free T4 2-3 ...
Is there a role for cinacalcet suppression testing when evaluating patients for suspected primary hyperparathyroidism who also have recurrent calcium containing kidney stone disease?
I understand the physiology upon which the cinacalcet suppression test is based. However, I have not used it in my practice. Once I see a discordant result between a parathyroid hormone level and its main determinants: serum calcium, phosphorus, and vitamin D (or 1, 25-vitamin-D), I use a sestamibi ...
Is intracranial hemorrhage a contraindication for valproic acid?
The short answer is no. Valproic Acid (VPA) can cause bone marrow suppression leading to thrombocytopenia, as well has hypofibrinogenemia. Through these mechanisms, and possibly others, platelet aggregation is reduced, which may place one at risk for hemorrhagic expansion, but in my experience, and ...
Can TPO agonists, like avatrombopag or lusutrombopag, be used for patients with chronic thrombocytopenia and new acute portal vein thrombosis?
A caveat before answering - these tend to be very difficult clinical situations in a population that often has cirrhosis and has a very difficult-to-predict hemostatic picture (whether they are prohemorrhagic or prothrombotic from the underlying liver disease).I would refer you to some of the excell...
How would you decide between conservative management vs. ILR or pacemaker for asymptomatic nocturnal bradycardia/pauses (as an example rates in the 30s, pauses ranging 4-12 seconds) in the absence of bradyarrhythmias during the day and ECG with normal intervals, and not otherwise on medications to slow down HR?
The guidelines are clear in stating that patients with symptomatic bradycardia or higher degree heart block during waking hours would benefit from pacing, but determining symptom-rhythm correlation is not always easy. In sinus node dysfunction, there is no established minimal HR or length of pause t...