Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
When should one consider obtaining a cardiac MRI in ischemic stroke patients?
This is a terrific question. Cardiac MRI is increasingly utilized in the diagnostic evaluation of ischemic stroke and can uncover clinically covert cardiovascular disease. The clinical utility in ischemic stroke is most in patients with concern for LV thrombus (low EF or recent anterior ST elevation...
Should you consider thromboprophylaxis, even for low-dose lenalidomide maintenance, post-autologous transplantation?
In the event there are no adverse contraindications for the use of thromboprophylaxis, yes, I recommend the use of a minimum of 81 mg of aspirin daily with a low dose of lenalidomide. In this meta-analysis (Chakraborty et al., PMID 31913498), the risk of venous thromboembolism was low with a low dos...
What is your approach to tapering therapy in patients with pulmonary sarcoidosis who are asymptomatic with stable pulmonary function and imaging?
We generally do not use weight-based dosing for treating sarcoidosis but often will use 20 mg daily (0.25 mg/kg) as a starting point. If a patient is newly started on prednisone, then we may use a gradual taper 20 mg daily for 1 month, then 15 mg daily for 1 month, then 10 mg daily until they are re...
What postural change in FVC is suggestive of respiratory muscle weakness?
In our practice, an assisted ventilation clinic which is enriched with patients who have diagnosed neuromuscular disease and/or chronic respiratory failure of unclear etiology, we often use 12% or 200cc simply by analogy to the criteria we use to assess bronchodilator responsiveness during PFTs. Alt...
Do you recommend a particular antiresorptive/anabolic agent for patients who are at high risk for fractures but have high risk of osteonecrosis of the jaw?
Teriparatide has improved bone healing in patients with osteonecrosis of the jaw, so would be a good choice for patients at high risk of ONJ.
Is a daily prophylactic dose of aspirin appropriate for patients with coronary artery calcification by Chest CT or an elevated calcium score?
There are no good studies directly answering this question. However, most studies that have looked at statin use in patients with elevated coronary calcium scores have found that many of those patients are also on aspirin 81 mg daily. My own practice is that I would certainly use a statin in patient...
What is your approach to management of intradialytic hypotension and autonomic dysfunction in a patient with ESKD?
Decreasing dialysate temperature to 35.5 to 36 degrees has, in my experience, caused a marked decrease in intradialytic hypotension. We use midodrine in some instances. The decreased dialysate temperature is systemwide in all cases in our units.
What are your practice recommendations regarding live vaccinations in infants/children of women who are currently on DMARDs and are breastfeeding?
This question needs some clarification to provide an exact answer. However, in regards to DMARDs in lactation, per the ACR 2020 Reproductive Health Guidelines and resources like LactMed and Mother to Baby (both free!), Methotrexate, Leflunomide, and Mycophenolate are not recommended in lactation. Th...