Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients with acute intermittent porphyria when it comes to fasting for religious reasons?
This is a very difficult question and it depends on the individual patient, their disease severity, their particular triggers, and how they have done in the past with caloric restriction. The patient may want to speak with a clergy member for guidance in this situation as well. For inst...
Would you recommend a SGLT2i for a non-diabetic patient with recurrent uric acid or calcium phosphate nephrolithiasis?
No. A major risk factor for uric acid stones is low urine pH. A major risk factor for calcium phosphate (as opposed to calcium oxalate) stones is high urine pH. I am not aware that SGLT2 inhibitors substantially change urine pH. Stephen B. Erickson, MD
Would you recommend dual antiplatelet therapy or anticoagulation for a patient previously on aspirin who has a breakthrough stroke with history of CADASIL?
CADASIL is a genetic condition with a presumed mechanism of vascular injury to be disruption of the blood-brain barrier and non-atherosclerotic angiopathy. Thus, it makes sense that no anti-thrombotic has been show to reduce stroke risk. It's expert consensus to do daily aspirin, but this is more to...
What is the optimal antithrombotic management, if at all, in patients with incidentally identified findings of multiple silent embolic appearing cerebral infarcts?
It is important to confirm the pattern is embolic. If unsure, input from a specialized physician (such as vascular neurology or neuro-radiology, if available) can aid in confirming the diagnosis. Various white matter findings may mimic an embolic pattern, and distinguishing between unilateral...
What is the role of non-prednisone oral glucocorticoids in the management of systemic rheumatologic disease?
I saw this question and thought it was really interesting. I did some preliminary research on the topic and was amazed at how little is actually written in the scientific literature. Perhaps someone reading this can perform a search and offer some thoughts. I decided to write to start a dialogue on ...
Is there a role for levothyroxine in managing the symptoms of a patient with euthyroid Hashimoto’s thyroiditis?
No, there is no role for levothyroxine in the management of symptomatic, euthyroid patients with Hashimoto’s thyroiditis. However, in some guidelines, serum TSH levels are recommended to be less than 2.5 milliunits per liter in women with positive TPO antibodies, who are pregnant or planning pregnan...
Do you routinely use anti-resorptive medications in patients who have osteoporosis and longstanding hypoparathyroidism?
If a patient has hypoparathyroidism, I am unwilling to use bisphosphonates or denosumab because of fear of significant hypocalcemia. I will use other agents to treat their osteoporosis.
For which patients with calciphylaxis would you recommend a parathyroidectomy?
In those with refractory hyperparathyroidism (typically PTH above 800-1000 pg/mL) despite medical therapies like cinacalcet.
How do you manage Raynaud's symptoms that develop in patient on CGRP inhibitors?
Research and practice combined, I have worked with the CGRP-receptor antagonists or gepants and CGRP-antibodies for over 20 years. I have not seen or heard of Raynaud's symptoms as a side effect of those medications, which, across the board, are very well tolerated. Hence, I would like to learn more...
When do you consider discontinuation of treatment in pediatric patients who have responded well to preventive migraine medications?
This is an excellent question and not necessarily straightforward to answer, as there are no current definitive guidelines to determine optimal duration of successful migraine preventive treatment and the best method of preventive medication discontinuation.If you look at the most recent pediatric p...