Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What work up do you recommend for persistent subclinical hyperthyroidism with decreased RAI uptake and negative thyroid antibody tests?
If the RAIU is very low, then this may be subacute thyroiditis. Lymphocytic or silent has no biochemical confirmatory tests. If there is pain, this suggest pseudogranulomatis subacute thyroiditis associated with a high URI and a recent viral infection. The other choice is they have some nodular thyr...
What are the implications of immunosuppressive therapy in a chronic asymptomatic T cell lymphopenic adult undergoing lung transplant evaluation?
The details of T cell lymphopenia are not mentioned for this patient. Idiopathic CD4 T cell lymphopenia is a recognized clinical syndrome which has been studied extensively (Lisco et al., PMID 37133586). The need for lung transplant is not detailed and raises the question if the two are related. It ...
Do you recommend holding ACE inhibitors, ARBs, and SGLT2 inhibitors for patients with chronic kidney disease and malignancy who are about to start high-dose intravenous methotrexate?
This is obviously an opinion-based question since there are no clinical data on this topic. If a patient has risk factors for AKI (underlying CKD, advanced age, low body mass) then it may be reasonable to hold RAAS blockers prior to treatment and resume following the completion of that cycle of high...
Do you recommend dosing potassium citrate three times or two times daily for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
I recommend twice daily dosing to help with compliance. I monitor 24-hour urine citrate and increase the dose rather than frequency if adequate urine levels are not achieved. Stephen B. Erickson, MD
Is there a particular prokinetic agent that you recommend if a patient has failed both PPI and TCA in the treatment of suspected functional dyspepsia?
In general, the evidence to support the use of prokinetics in functional dyspepsia (FD) is not strong. The rationale for using a prokinetic agent for FD is to improve gastric emptying time in the subset (about ¼) of patients who delayed gastric emptying which is usually mild. The three prokinetic ag...
Would you consider using IVIG for POTS in the absence of any clear autoimmune condition or abnormal antibodies?
I completely agree with the answer above. It would be a pretty rare consideration, overall. Recent placebo-controlled and blinded studies examining the efficacy of IVIG for idiopathic or antibody-associated (FGFR, TSHDS) small fiber neuropathy found no benefit of the treatment in terms of small fibe...
Do you transition to oral antibiotics to treat uncomplicated Staphylococcus aureus bacteremia after patients have improved with intravenous antibiotic therapy?
I agree with Dr. @Dr. First Last, further these are tissue drugs more than bloodstream drugs. That’s why they don’t work well in bacteremia.
How do you approach folate supplementation for methotrexate-related side effects?
All MTX users should be taking some form of folate supplement. Either daily folic acid or weekly folinic acid are used and generally are effective. Tracking the RBC MCV is one way to ensure that patients are receiving adequate folate supplementation.The question has been raised whether folate supple...
Would you consider PTH analogue in a patient with mildly elevated PTH?
This is a complicated question because there is not any substantial literature. Almost all clinical trials with teriparatide and abaloparatide excluded patients with elevated PTH levels. However, there is considerable anecdotal experience. I have surveyed many colleagues with considerable experience...
How do you approach a patient with elevated bone specific ALP (>2X the normal limit), but no other evidence of Paget's disease?
There are other causes of elevated bone alkaline phosphatase e.g. osteomalacia. Check blood calcium, magnesium and phosphate, PTH and 25-OH-vitamin D. If PTH is elevated and no CKD, check 24-hour urinary calcium and creatinine.