Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What therapies have you found most effective in treating teenagers with recurrent CARP?
I have found CARP to be uniformly responsive to minocycline. In my experience, the incidence of recurrence is low and normally responds to minocycline.
Are there instances when you dose sodium zirconium cyclosilicate more than once daily for long term therapy for patients with end stage kidney disease and hyperkalemia?
Not for long-term therapy. I definitely use it more than once daily to lower serum potassium levels acutely, in patients who have clotted their access and are unable to dialyze for 1-2 days until they get decloted, etc. I would imagine that it would be safe to use long-term more than once daily exce...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
What class(es) of antihypertensives should be considered next for refractory hypertension in a patient compliant with high doses of Entresto, chlorthalidone, amlodipine, clonidine, and spironolactone if they previously did not have any improvement on beta blocker or hydralazine and work-up for secondary causes were unremarkable?
Minoxidil remains a rarely used but potent option.
What approaches do you take to prevent worsening kidney function for patients with chronic kidney disease who have an upcoming outpatient CT scan with iodinated contrast?
If CT is really necessary, if not very high risk just encourage moderate oral hydration before and after. May hold diuretics if this can be done safely. If very high risk try to get IV saline for a few hours prior.
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
Do you always perform salivary gland biopsy to confirm the diagnosis In patients with suspected seronegative Sjogren's syndrome?
I often struggle with the decision of obtaining a biopsy in suspected Sjogren's in a person who is seronegative, when the main issue is dryness, and the main reason is that I wonder if it will make a difference in management. When I was a Rheumatology fellow, I was taught to give Hydroxychloroquine ...
How do you approach managing patients with diabetic kidney disease and proteinuria who develop hypoglycemia after initiation of a SGLT2 inhibitor?
I would first determine if there are other medications the patient is on that reduce the blood glucose. Hypoglycemia with SGLT-2 inhibitors is usually due to something else. Another medication is most likely. Could be very poor dietary intake. Could lower the dose if not on the lowest available dose...
Given recent data from the REPRIEVE trial, how will you adapt your practice with regards to prescribing statins to patients living with HIV?
This randomized controlled trial (Randomized Trial to Prevent Vascular Events) found that, for people living with HIV between the ages of 40 and 75 years who were taking pitavastatin calcium, the risk of major adverse cardiovascular events was lowered by 35% and the risk of cardiovascular death was ...