Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Are there patients with granulomatosis with polyangiitis on maintenance rituximab therapy for whom you do not co-administer glucocorticoid therapy?
I think this is a great question. @Dr. First Last et al (NCT01933724) have conducted a study to answer that question (conveniently called TAPIR). In their analysis that was presented 1 week ago at the International Vasculitis Workshop, they found that patients on low-dose prednisone along with other...
Do you extend the duration of maintenance therapy past 24 months for patients with ANCA glomerulonephritis who have multiple organ involvement?
The duration of maintenance therapy in patients with AAV depends on many factors and should be individualized. Some factors that are associated with a higher risk of relapse include PR3 positivity, seroconversion from negative to positive, ENT disease, use of a tailored approach to RTX dosing, and u...
How do you risk stratify patients with different WHO groups of pulmonary hypertension prior to non-cardiac surgeries?
First, I would direct the audience to recent AHA guidelines on the perioperative management of PH in non-cardiac surgery. Rajagopal et al., PMID 36924225In general, the severity of pulmonary hypertension and relevant comorbidities are likely more important than the WHO group. In patients with CTEPH,...
How would you approach secondary stroke prevention in an adult with Hemoglobin SC disease?
Stroke is less common in HbSC disease than it is in HbS homozygotes (Ohene-Frempong et al., PMID 9414296). Thus, there are no studies focused on primary or secondary stroke prevention in HbSC disease. Recent guidelines for stroke management were “silent” on stroke in HbSC disease (DeBaun et al., PMI...
What is your approach for steroid dosing for patients with ANCA vasculitis on induction treatment with rituximab, avacopan, and glucocorticoid therapy?
I do not personally have a one-size-fits-all approach. Remember that ADVOCATE had a screening window of up to 2 weeks where many patients got steroids before they were randomized. At the time of randomization, patients had to be on less than 20mg of prednisone which was tapered over 4 weeks.In addit...
What is your approach to de-escalation of asthma therapy if patients have remained clinically stable on triple inhaler therapy and a biologic agent?
Since the reason most folks need biologics is prednisone and considering the side effects, getting patients down to the lowest dose is beneficial.
How do you treat CTD-associated organizing pneumonia?
I agree with what Dr. @Dr. First Last has said. To answer your question specifically, organizing pneumonia is slightly different to other forms of ILD. OP tend to have much better response to steroids in general. As with most other ILD patterns, CTD-OP has slightly worse prognosis than COP. So I am ...
What is the typical timeline for remission of autoimmune hypoglycemia?
Insulin autoimmune syndrome (IAS) or Hirata disease is a rare disorder characterized by hypoglycemic episodes due to the presence of high titers of insulin autoantibodies (IAA). The disease was first described in 1970. Because of its rarity, large clinical experiences with this disorder are limited....
How do you counsel patients with ALS on the benefits of enteral nutrition?
I agree with Drs. @Dr. First Last and @Dr. First Last but what I find frequently is that patients are reluctant to have PEG because of a number of psychological factors; fear of the surgery, fear of having a tube, fear of disease progression, fear that it will keep them alive indefinitely as in the ...
What is your approach to GDMT uptitration (particularly dosing for ARBs/ARNIs/MRA) if there is further evidence of renal dysfunction, especially in situations with worsening AKI on CKD?
Titration of RAAS inhibitors in the setting of AKI on CKD is challenging. First, look at the patient: if they have an increase in Cr after an increase in the RAAS inhibitor but no/stable HF symptoms and appear euvolemic on examination, then I will decrease diuretic therapy and see if the Cr improves...