Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
After confirming the patient is not on NSAIDs, how do you approach acute ileitis on biopsies in a patient without symptoms or with only mild loose stools?
Is diarrhea inflammatory? What is her level of calprotectin? A useful biomarker to follow. Aphthous ilieitis does not have risk features for progressive Crohn’s that, at least at this time, does not require an advanced agent. You can use symptomatic agents (loperamide, cholestyramine, etc.) to asses...
How do you determine the optimal time to restart a diuretic in a patient with cirrhosis, ascites, and lower extremity edema who presented with acute kidney injury that resolved with IV albumin and holding diuretics?
Good question. It is tricky. Spironolactone can be resumed fairly quickly. With loop diuretics it is harder to resume them. If necessary, I would resume at lower dose and slowly uptitrate as needed with close monitoring. Ideally, it is better to do frequent paracentesis with albumin infusion than gi...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
What is your antipsychotic of choice and general titration regimen in the outpatient setting for a patient with dementia and behavioral disturbances (assuming reversible causes such as urinary retention, constipation, etc. have been addressed)?
While not set in stone and knowing that there is a black box warning, make sure you get informed consent. I start with low doses of quetiapine (12.5 to 25 mg), as it has the shortest half-life, and will use it twice or 3 times a day. This allows for quicker recovery if they are too sedated. Dependin...
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
In what clinical circumstances do you use repository corticotropin injections in the management of a glomerulonephritis?
Personally, I have never used ACTH gel, but two specific disease states come to mind: steroid-resistant FSGS and membranous nephropathy. In one study, the partial remission rate for steroid-resistant FSGS was 29%, and for post-transplant recurrence of FSGS, 55%. For MN, the complete remission rate w...
Are systemic effects from corticosteroid use greater with budesonide rinses compared to nasal sprays?
With the increased use of budesonide nasal rinses for chronic rhinosinusitis and nasal polyps, it seems appropriate to ask about the systemic effects of rinses versus nasal sprays. Two publications address this point, both of which are in the International Forum of Allergy and Rhinology. The first (...
Is there evidence that certain PPIs provide superior clinical efficacy compared to others in real-world practice?
While there are some differences between PPIs in terms of metabolism, bioavailability, and duration of acid suppression, generally speaking, in clinical practice, the efficacy of different PPIs is comparable. With that said, some differences include dexlansoprazole's dual-release nature which genera...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...