Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your treatment approach for hidradenitis suppurativa?
In HS, we talk about a "window of opportunity." It's the idea that since HS causes tissue damage, scarring, and tunneling, treatment becomes more difficult as the disease progresses. A delay of 10 years between symptom onset and starting adalimumab was associated with a 1.92x higher odds that the pa...
Do you recommend holding metformin in a patient with chronic kidney disease who has an upcoming CT contrast study?
I actually do. Over the years I have seen a number of cases of metformin induced lactic acidosis. Although it is very hard to predict who will have it. I would like to be on the safe side.
What are your management strategies for patients with recurrent uric acid nephrolithiasis and chronic kidney disease who have persistent hypocitraturia and acidic urine pH?
This is a good question. The primary goal is to correct the urine pH to at least 6 and preferably 6.5, regardless of renal function. Hypocitraturia is not a critical issue in uric acid stones disease, though it will likely respond to therapies listed below. Concurrent chronic kidney disease does not...
Do you interpret failure to develop hypernatremia with prolonged water deprivation (such as for 12 hours) as evidence against diabetes insipidus even if the urine osmolality is just below normal?
This test indicates that this patient has fairly good urinary concentrating ability, but does not meet most criteria for "normal" since the osmoles did not go over 600. Since diabetes insipidus is a spectrum disorder, this result does not completely rule out the possibility of very mild diabetes ins...
What is the minimum eGFR at which we should avoid initiating SGLT2i therapy?
The minimum eGFR to avoid initiating SGLT2i is different depending on the medication. Canagliflozin or Invokana is less than 30 ml/min. Dapagliflozin or Farxiga is less than 25 ml/min. Empagliflozin or Jardiance is less than 20 ml/min. With recent study suggests you still can continue the therapy wi...
When do you consider prescribing medications such as Aricept in patients with Down Syndrome who start having memory issues?
By age 60, there's a 60% chance that most people with Down syndrome will begin developing symptoms or signs of Alzheimer's disease. However, it’s important to also keep in mind that there are many other reasons why a person with Down syndrome may show signs of decline and it may not be Alzheimer's d...
When would you suspect metabolic myopathy and what is your approach to initial workup?
Great question and really important to rheumatology practice. As always, a history and physical exam is the best initial diagnostic tool. It’s a little bit difficult because of the sheer number and heterogeneity of non-autoimmune myopathies that clinicians may encounter, but a few general principles...
What is your goal ferritin level in pregnancy?
The goal is really to avoid iron deficiency and <30 best defines this state. Need to be wary of circumstances such as inflammation where the ferritin level may be falsely high even in the setting of reduced body iron.
Do you send CSF or serum ACE levels in the workup of neurosarcoidosis?
Unfortunately, serum and/or CSF ACE levels are just not sensitive or specific enough to guide the diagnosis or treatment of sarcoidosis, particularly neurosarcoid. Rather, imaging characteristics, specific organ system involvement, and biopsy results are much more useful in my practice.Bradshaw et a...
Would you increase or maintain the same initial dose of methimazole for treatment of hyperthyroidism if symptoms and thyroid tests improve but are not normalized?
Starting a hyperthyroid patient on the correct dose of methimazole (MMI) is of paramount importance. According to the 2015 ATA guidelines on the management of hyperthyroidism (Ross et al., PMID 27521067), the initial methimazole dose should be based on the patient's serum free T4 level: Free T4 2-3 ...