Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider PTH-analog therapy in a woman with osteoporotic vertebral fractures who has asymptomatic non-obstructive renal stones and normal 24-hour urine calcium level?
With the limited information posted, my answer would be yes. I would likely choose abaloparatide as it seems to have less of an issue with hypercalciuria than teriparatide. Another option for an “anabolic" drug would be Romosozumab which would not be a drug about which hypercalciuria is a concern.
When would you consider neuro-stimulants in post-stroke patients?
To my knowledge, there are no large, randomized trials supporting the use of neurostimulants in stroke rehabilitation. When patients are too sleepy to participate in therapy, I have been known to use very low-dose methylphenidate or modafinil. Levodopa has also been tried with mixed results.
Do you recommend the HPV vaccine for patients with recalcitrant verruca vulgaris?
Yes, I recommend the HPV vaccine for children and adolescents of eligible age. I have seen warts resolve after vaccine administration. There are reports of dramatic resolution after vaccination. A cross-protective mechanism of action is suggested. Literature suggests there may be an age-dependent re...
Do you recommend initiating a potassium sparing diuretic in patients with recurrent nephrolithiasis who have hypercalciuria but do not tolerate thiazide diuretics?
No. The idea of using a thiazide diuretic as a preventive treatment for calcium-containing stones is its hypocalciuric effect. Potassium-sparing diuretics do not have this ability. Loop diuretics worsen hypercalciuria and, in general, are inappropriate for use in calcium stone formers. One could con...
Would you consider GLP1 R agonist therapy in a patient with a history of severe gallstone pancreatitis that is now post cholecystectomy?
In the context of shared decision-making, I would consider prescribing an GLP-1RA on someone with a history of severe gallstone pancreatitis post cholecystectomy. The critical issue is for the patient to understand the uncertainty about the safety of the approach and be willing to take on that risk....
What is your approach to ongoing assessment and medication tapering in well controlled discoid lupus without systemic features?
As with many systemic lupus (SLE) complications, the patient with discoid lupus (DLE) is often best managed by a rheumatologist in tandem with a specialist of that complication, in this case, a good medical dermatologist experienced with cutaneous lupus. Although I think I am good at telling most ac...
How long do you recommend patients hold aspirin for prior to and after undergoing a native kidney biopsy?
I usually recommend that patients hold aspirin (ASA) 7 days prior to and one day after undergoing a percutaneous native kidney biopsy. 30 mg of ASA irreversibly inhibits cyclooxygenase a key platelet enzyme for the synthesis of thromboxane and the effect lasts for approximately one week. This effect...
Are there instances when you prefer serum creatinine over cystatin C when estimating GFR in a patient with CKD?
Overall serum cystatin C correlates better with measured GFR than does serum creatinine. The main block to more widespread use of cystatin C is its cost. I personally have not had an experience where the serum creatinine has been a better measure of GFR as opposed to serum cystatin C but there is da...
How do you approach monitoring when using combination JAK inhibitors and methotrexate in RA?
It is important to return to the package insert and/or the original clinical trials for these medications when considering options for care and use. Tofacitinib, for example, when tested for the management of rheumatoid arthritis, was in phase 2 and 3 studies in combination with DMARDs, including me...
What is your approach to counseling and management of patients with severe symptomatic OSA whose PAP devices have been recalled?
Continue to use it with or without a microbiological filter. The latter is not necessarily recommended by Respironics but is an option nevertheless.