Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage a patient with osteoporosis on denosumab who develops significant renal insufficiency where it is difficult to continue denosumab due to increased risk of hypocalcemia (i.e. eGFR in the low 20’s)?
This is an interesting question. Denosumab, unlike bisphosphonates, does not have a warning about use with renal insufficiency. However, denosumab does reduce osteoclast activity for a few weeks after the injection, and this can cause hypocalcemia in patients with renal insufficiency as these patien...
In which patients with chronic kidney disease and low 25-OH vitamin D levels do you prefer weekly ergocalciferol to daily cholecalciferol supplementation?
Ergocalciferol (D2), the plant-based form of Vitamin D, and cholecalciferol (D3), the animal-based form, are essentially equivalent in potency with perhaps a small, clinically insignificant edge favoring D3. They both can be given at long interdose intervals; monthly doses provide the same impact on...
What is your blood pressure goal for the first three months after kidney transplantation?
We target a BP goal of < 130/80 mmHg in line with KDIGO guidelines. (1)There are no RCTs or other high-quality evidence looking at BP targets in kidney transplant patients that compare outcomes, graft survival or mortality. One small RCT (ESCORT trial) in pediatric transplant recipients, comparing i...
What are your diagnostic and management approaches beyond statin therapy for hyperlipidemia in young adults with significantly elevated LDL levels in isolation (i.e. reasonable calcium score, normal lipoprotein A levels)?
It depends on other factors such as the presence of diabetes and a family history of early CAD. If either of these is present, I push hard with statins and possibly add Zetia to get the LDL down to 60-70. I also push for lifestyle changes such as moderate daily exercise, weight loss, and reducing li...
What would be your next step in treating a patient with osteoporosis who developed AFF on denosumab and who then completed one year of romosozumab?
There is no evidence-based answer for this question. First of all, the development of AFF while on osteoporosis doses of denosumab is very rare. It usually occurs in people who have previously been on bisphosphonates. I would most appropriately assess fracture risk after the romo and then determine ...
Do you recommend switching to a non-dihydropyridine calcium channel blocker with the goal of decreasing proteinuria in a proteinuric, hypertensive CKD patient already on a dihydropyridine calcium channel blocker?
Blood pressure control has a more powerful effect on reducing proteinuria than the type of calcium channel blocker. It is often difficult to achieve the goal of BP < 130/80 mm Hg while on a non-dihydropyridine CCB. I chose to focus on other anti-proteinuric agents like SGLT2-INH, MRA, and ACEi/ARB, ...
What is your blood pressure goal for a pregnant patient on hemodialysis?
This is a great question with very little evidence behind it. In pregnant patients, just as in non-pregnant patients, the target for BP should be based on their home readings between treatments, rather than readings at the beginning or end of dialysis. I target < 140/90 mm Hg, consistent with the ap...
How would you approach a patient who has well controlled SLE on HCQ but develops cotton wool spots on routine ophthalmologic screening?
Cotton-wool spots are estimated to occur in 10-15% of SLE patients. Etiology is either thrombotic pathology from associated APS, vasculitis or atherosclerosis. Treatment is targeted to the underlying etiology: eg anti-coagulation for APS, immunosuppression for vasculitis or minimization of atheroscl...
Do you recommend performing cognitive testing in the clinic to determine the blood pressure target in patients 80 years or older?
SPRINT-MIND helps to answer this question. The total number of individuals developing dementia (the primary outcome in SPRINT-MIND) was fewer then expected after a median intervention period of only 3.3 years. This made SPRINT-MIND underpowered to detect the effects of intensive BP reduction on deve...
How do you counsel patients regarding alcohol intake when prescribing DMARDs other than methotrexate?
I always inquire about alcohol intake before starting any drug with a known issue of hepatotoxicoty, using the “Law of Two” I learned as an intern: alcohol abusers under-report their intake by a factor of two. Assuming there is no such red flag to avoid the drug, I tell my patients that alcohol is n...