Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you start PAP in patients who have an overall AHI of less than 5 but demonstrate significant apneas/hypopneas in REM sleep?
In general, there is a very poor relationship between AHI and symptoms, particularly sleepiness. Some patients with a low AHI are quite sleepy and others with a high AHI have no symptoms. Thus, in general, if a patient has an elevated AHI, even if minimally elevated, and I have no other explanation ...
Should JAK inhibitors and anti-IL6 medications be avoided in patients with known diverticulosis?
The development of diverticulitis, including complications such as bowel perforation, has been reported in patients taking JAK and IL-6 inhibitors (for example, see here and here). As a result, a history of diverticulitis is a relative contraindication for these agents (and carry a “use with caution...
In difficult cases, what is your approach to find a causative agent of fixed drug or fixed food eruption?
I don't think there is any answer other than advising the patient of the natural course/behavior of the eruption and having them keep a strict journal of all intake until the culprit is determined. Data on testing has been mixed at best (Jayasundera & Watts, PMID 38336399) -- though there may be a r...
How frequently do you check lab work in patients with stable myasthenia gravis?
It depends on what medications they are on! If patients are on pyridostigmine only (some mild ocular MG cases), none. If patients are on monotherapy with eculizumab or ravulizumab, I check none. On steroids: at least twice a year A1c, BMP, annual DEXA scan for osteoporosis, annual eye exam. On azat...
How do you manage patients with SLE undergoing assisted reproductive therapy with estrogenic effects?
For patients undergoing any form of assisted reproductive technology (ART), it is important to assess their SLE disease activity. If a patient has moderate to severe SLE disease, I recommend delaying ART until we have better control of their disease. Once we plan to move forward with ART, I check an...
What is your approach to managing hypokalemia in patients with Bartter syndrome who are on high doses of potassium chloride but cannot tolerate amiloride or ACEi/ARBs due to low blood pressures?
Since prostaglandin level is typically high in patients with Bartter syndrome, NSAIDS can be tried to treat hypokalemia in these patients who cannot tolerate amiloride or ACEi/ARB due to low blood pressure. However, close monitoring of renal function is required if NSAIDS were to be given in these p...
Do you recommend IM Kenalog injection for refractory CRSwNP in a patient already on maximal therapy?
For refractory CRSwP on maximal therapy, IM Kenalog would not be my drug of choice. I would rather suggest Dupixent. A number of published papers including some from Klaus Bachert clearly show the benefit of Dupixent in this subgroup of patients. IM kenalog might help for a short time, but Dupixent ...
For hypogammaglobulinemia as a complication of successful treatment, do you empirically start prophylaxis with either 400 mg/kg monthly for IVIG or 100 mg/kg weekly for subcutaneous immune globulin?
Most of the data to support IVIG for hypogam comes from CLL literature. Data in those post-transplant and post-CAR T are limited. IVIG has a reputation of being a bit of a panacea, but I challenge that notion. We investigated the implementation of an IVIG stewardship plan to limit IVIG usage just fo...
Do you continue methotrexate in patients with inflammatory arthritis who develop non-melanomatous skin cancer while on therapy?
Data on methotrexate use and the increased risk of non-melanomatous skin cancers has been conflicting, suggesting an increased risk or a neutral risk. A recent case-control study published in the British Journal of Cancer (Polesie et al., PMID 36739322) did suggest an increased risk of both squamous...
Can transudative pleural effusions lead to trapped lung?
Yes. I’ve seen it many times especially in patients with longstanding CHF and/or CKD. With a persistent effusion of any type, the pleura can respond by forming a peel resulting in a non expanding lung.