Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider teriparatide use in a patient with prior radiation therapy, given that the black box warning regarding osteosarcoma risk has been removed by the FDA?
The rat studies were unequivocal that both teriparatide and abaloparatide increased the risk of osteosarcoma in rats given high doses for essentially their entire lifespan. Upon approval of teriparatide, Lilly agreed to a post-marketing pharmacovigilance study that started out as a case-finding stud...
Is there a role for SGLT-2 inhibitors in the treatment of chronic hypomagnesemia?
A meta-analysis of 18 randomized controlled trials showed that the use of SGLT2 inhibitors can result in a significant increase in the serum magnesium level. These trials, however, were not specifically designed to assess the effect of SGLT2 inhibitors on the serum magnesium level. Studies have show...
Do you have a preferred oral magnesium formulation for patients with hypomagnesemia secondary to Gitleman syndrome and who also have chronic diarrhea?
Compared to other magnesium supplements, magnesium glycinate tends to cause less diarrhea and is better tolerated by my patients with Gitelman syndrome.
How do you manage a DOAC if interested in testing for lupus anticoagulant?
Testing for anti-phospholipid antibodies encompasses two broad categories of testing. One is an ELISA based (aka solid phase) set of tests that include anti-cardiolipin and anti-beta 2 glycoprotein I antibodies. ELISA assay are not affected by DOACs. For the second lupus anticoagulant (aka fluid pha...
What are the indications for anticoagulation in splenic infarctions?
A great reminder that splenic infarct relates to ARTERIAL thromboembolism and not to VENOUS VTE. Too often, I see massive, blind thrombophilia work-up for (incidentally) detected splenic infarcts.
How do you approach evaluation for underlying rheumatologic disease in patients with chronic asymptomatic thrombocytopenia?
APL testing as well as evaluation for SLE and Sjogrens with complement, urine, antibody testing, not just an ANA.
How do steroids and/or DMARDs affect biopsy results if a renal biopsy for suspected lupus nephritis is delayed?
In contrast to GCA/TA, where the Mayo clinic has published data that steroid treatment for as much as circa 2-4 weeks is unlikely to result in a false-negative biopsy, as long as accounts for the skip phenomenon and carefully examines multiple sections of the biopsy, I am unaware of similar informat...
Is there a BMI cutoff for which you no longer recommend kidney transplantation in a patient with end stage kidney disease and obesity?
BMI cutoff for transplantation varies widely across institutions so it is important to know your local transplant center guidelines. In general, a BMI > 40 kg/m2 is considered to be a contraindication with many centers. Some centers will recommend bariatric surgery (often not a bypass or duodenal sw...
What can prostate patients do for sexual function while on ADT?
While libido drops for most men on ADT, sexual function is still an important component for many, and educating on what to expect will help prevent disappointment or confusion. First, some men can get an erection with testosterone suppressed, but it is less common and not as firm an erection as wha...
How do you taper phenobarbital in a patient with epilepsy?
Since the risk of withdrawal seizures is high, it's best to administer clobazam. The dose depends on the dose of phenobarbital. After a week, clobazam can be discontinued gradually, tapering off without the risk of withdrawal.