Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider anticoagulation for a young patient with a recent embolic stroke and newly diagnosed global cardiac hypokinesis with ejection fraction of less than 25%?
Yes, I would consider anticoagulation but the evidence is indirect. There is reasonable data in persons with heart failure with reduced ejection fraction that ischemic stroke is reduced with anticoagulation compared to antiplatelet therapy alone. But essentially all large RCTs are limited in that th...
How would you approach potentially tapering maintenance mycophenolate mofetil in a patient with a history of class IV LN that has been in remission for >5 years?
I would tell her, absolutely, and I'm sorry I did not consider this 2 years ago after being in remission for 3 years. ;-) I then proceed to explain the options and make a shared decision-making process. CHOICE 1 (my recommendation): A significant enough lupus nephritis patients are not in true patho...
What is your approach to further workup, monitoring, and treatment of Sjogren's syndrome patients with positive cryoglobulins but no clear signs of vasculitis?
Sjogren's disease patients who have cryoglobulinemia should have a thorough examination including a neuro examination to evaluate for vasculitis. Laboratory evaluation should include urinalysis, creatinine, and urine protein to creatinine ratio to evaluate for renal involvement. Serum and urine immu...
When would you consider using G-CSF in patients with rheumatic disease who have received cyclophosphamide?
Our primary concern would be our patients with systemic lupus erythematosus. There are reports of severe flares in SLE patients treated with G-CSF (vasculitis and nephritis; Vasiliu et al, PMID 16832843) and even reports of cardiac arrest (Ragsdale & Hall Zimmerman, PMID 34748466).Of course, this ne...
Do you recommend uric acid lowering therapies for asymptomatic hyperuricemia in chronic kidney disease?
There is conflicting literature about what to do with elevated uric acid levels in CKD patients. In my practice, I do usually treat high uric acid level over 10 even if asymptomatic. I definitely give allopurinol earlier if elevated uric acid levels and history of kidney stones, even if they are not...
How do you approach hypocomplementemia in Sjogren’s without features of lymphoma?
Low C3 and/or C4 support immune activity. Therefore, I look at all domains that SjD can potentially affect for further clues. Low complements in SjD are associated with systemic disease activity (Ramos-Casals et al., PMID 24162151). Low C4 may suggest a more severe disease (Pavlakis et al., PMID 223...
What strategies do you employ for adjusting the dosage of levothyroxine in hypothyroid patients who experience significant weight loss or are initiated on GLP-1 receptor agonists?
In spite of significant weight loss, some patients may not require a dosage change for levothyroxine while others may require a dosage reduction. It is very reasonable to recheck a TSH with free T4 after a 10% weight loss to see if a dose adjustment is needed. Rapid weight loss may lead to a tempora...
When would you consider obtaining a cardiac CT in lieu of standard TEE for the detection of a left atrial appendage thrombus in atrial fibrillation?
TEE is still the gold standard for the evaluation of left atrial appendage thrombus. That being said, there is certainly a role for cardiac CT as well, especially in patients with esophageal pathology or other conditions that increase the risk or contraindicate the use of TEE such as significant thr...
How would you approach medication de-escalation in a patient with a history of rapidly progressive CTD-ILD who responded to and is currently on mycophenolate 3 grams daily and IVIG 2mg/kg monthly infusions and has been stable for two years?
This is an excellent question with the very little data to go by. We spend most of our time studying escalation of therapy and very little time discussing de-escalation. It has been my experience as a rheumatologist for almost 37 years that many autoimmune diseases initially can be quite immunologic...
How do you approach management of a patient with idiopathic PAH and +ANA, but no other current symptoms/signs of active rheumatologic disease?
(1) Of note, abnormal nail fold capillaroscopy is associated with PAH in several systemic immune diseases: This is famously true for systemic sclerosis, but there are also publications reporting this association for other diseases, notably those in the “lupus family“ like SLE and dermatomyositis. As...