Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you use oral fosfomycin as a treatment option for uncomplicated cystitis due to ESBL producing E coli?
Fosfomycin is one of the first-line drugs for uncomplicated UTI listed in the Infectious Diseases Society of America (IDSA) UTI treatment guidelines (these guidelines are currently being updated). It is the only single-dose drug approved for UTI and is an effective option. It does have activity agai...
When treating pancreatic body/tail lesions that result in significant dose spread to the spleen, what is your threshold to offer pneumococcal, hemophilus influenza, and meningococcal vaccines?
A really great question, and one that we don’t necessarily have a lot of data for guidance. There are some guidelines out there, though, that I think can be helpful to consider. The first is the recent guideline from ASCO on the vaccination of adults with cancer (Kamboj et al., PMID 38498792). In li...
Would you recommend cinacalcet for patients with recurrent nephrolithiasis who have hypercalciuria despite thiazide diuretic use and who also have an elevated PTH level without localizing parathyroid adenoma on imaging?
This is a tricky question with a nuanced answer. If the hyperparathyroidism is secondary, cinacalcet may have a role in treatment along with normalizing serum phosphorus and vitamin D. However, metabolically active kidney stones are unusual in advanced chronic kidney disease. If the hyperparathyroid...
Do you use the peri-operative management of biologics and DMARDs guidelines, which were mainly based on total hip and knee replacement surgeries, for all peri-operative surgical management?
The American College of Rheumatology Perioperative Guidelines focused on patients undergoing hip or knee arthroplasty. These guidelines can be a helpful starting place when thinking about medication management in patients undergoing other surgeries, but my recommendations for perioperative managemen...
Do you use asthma or EoE dosing if initiating dupilumab in a patient who meets criteria for treatment for both disorders?
I would do the higher dose (EoE) if starting it for both.
How do you approach the timing of DMARD initiation in patients with active RA who are on treatment for latent TB?
As the patient is already treated for latent TB, if they have not initiated DMARD therapy for RA, I would follow the guidelines and start conventional DMARD therapy. If the patient requires additional therapy because of insufficient response, I would choose a non-TNF inhibitor as the risk for TB rea...
Is omalizumab an option for a patient needing a specific antibiotic with an IgE-mediated reaction who continues to have reactions during a desensitization?
Omalizumab is FDA-approved for Asthma, Chronic spontaneous urticaria, chronic rhinosinusitis with nasal polyposis, and food allergy. It is a monoclonal antibody directed at IgE which will deplete circulating IgE and thus specific IgE on the mast cell and basophils will decrease. There is also likely...
How do you approach the management of persistent hyperphosphatemia in ESKD patients who are non-adherent to phosphate binders?
This is not easy. The first thing I usually do is try and find out why they are non-adherent. Is it due to side effects, cost, etc? Are there social reasons? For example, are they "embarrassed" to take binders if they are out eating with friends? Often, I find that I need to switch binders to see if...
Is it reasonable to consider the use of DOACs for LV thrombus management instead of coumadin?
I have no qualms whatsoever at using a DOAC instead of Vitamin K antagonist in this situation, provided that the patient doesn't have a mechanical valve. Endothelium is endothelium, so mechanistically I don't see much of a difference between using a DOAC to prevent/treat an LAA thrombus versus an LV...
What is the current recommendation for air travel after a primary spontaneous pneumothorax?
General guidelines including the British Thoracic Society recommend delaying air travel for at least 2 weeks following the radiographic resolution of a pneumothorax. However, recent studies have challenged this conservative approach. A study by Majercik et al., PMID 25494425 demonstrated that patien...