Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
What is the preferred first-line non-insulin agent in patients with ketosis-prone diabetes during "remission" and evidence of preserved beta cell function?
Ketosis-prone diabetes (KPD) is an atypical form of diabetes that has been found in various racial and ethnic groups (Asian Indian, South American, West African, African American and others). People with KPD may present with DKA without the autoimmune findings of Type 1 diabetes. After the DKA episo...
Would you start treatment for MAC in a patient with nodular bronchiectatic disease who has demonstrated radiographic progression but remains asymptomatic and smear-negative?
My default answer would be yes; this is a sign of progressive disease that will get worse without treatment. Having said that many things could be considered while making the decision, including patient preferences. First is there another cause? Does the patient have an exacerbation of bronchiectasi...
For patients <65 with significant intermittent steroid exposure who otherwise do not have risk factors for osteoporosis, when, if ever, do you recommend considering DEXA screening?
The FRAX guidelines recommend answering "Yes" for glucocorticoid use when a patient has received the equivalent of prednisone ≥5 mg daily for more than 3 months. However, many patients with rheumatoid arthritis have been treated with intermittent courses of corticosteroids over several years, which ...
Do you discontinue amlodipine or use an alternative approach to manage peripheral edema when it occurs as a side effect of the medication?
CCB edema (also hydralazine edema) are so underappreciated by non-nephrologists. Rarely does a clinic go by without me seeing some form of it. It is from vasodilation that allows gravity to increase capillary hydrostatic pressure, fluid moves out of vascular space to interstitial space and in that r...
What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?
Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...
Should an ischemic evaluation be considered in the diagnostic work-up for new-onset diastolic heart failure/HFpEF in patients without clear anginal symptoms?
The ischemic phenotype is a well-recognized class among HFpEF patients. For men, this usually manifests as macrovascular disease with epicardial CAD, and for females, the more common manifestation is microvascular disease with CMD. Therefore, ischemic evaluation should be considered as part of the w...
How would you approach management of nodular scleritis in the setting of suspected GCA?
Scleritis is probably a rare but real association with GCA. The rarity is such that I would not ignore alternative causes of scleritis. For example, ANCA-associated vasculitis could mimic GCA and syphilis has also been reported as a masquerade. Scleritis is usually divided into 5 forms: nodular, dif...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
Do you prescribe a low-dose tricyclic antidepressant as a gut-brain neuromodulator for a patient with IBS that has not responded to dietary modification and first-line pharmacotherapy?
Yes, I do. In fact, I consider a tricyclic like imipramine (highest GI effects) to be first-line pharmacotherapy.