Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When would you consider proceeding with antiarrhythmic drug load concurrently with DCCV as opposed to DCCV alone in patients with new-onset atrial fibrillation?
There is no expert consensus. If we are dealing with a first episode of AF, and we know that the arrhythmia has a short duration and the anatomic substrate is not severe, I would proceed with cardioversion alone. After all, we learned from AFFIRM that many patients randomized to "rate control" after...
How would you approach management of a patient with longstanding history of SLE, but having active psoriasis?
In addition to above, I would consider deucravicitinib. It has PASI75 scores that are in the 60s, and is in trials for SLE. Its phase 2 trials seemed promising. Other PO JAK inhibitors should be efficacious but may carry worse side effect profile. I have also employed PDE4 inhibitors such as po apre...
Are there instances when you recommend against a kidney biopsy in a patient with a single kidney who otherwise has indications for a biopsy, consents, and has no medical contraindications for the procedure?
I don't think so. These days the risks of having to do nephrectomy after kidney biopsy is very small and having a single kidney is a weak argument for not doing kidney biopsies. In my practice, a patient with a single kidney would get biopsied by interventional radiology to minimize the risk as much...
Do you prefer sodium bicarbonate or sodium citrate in your chronic kidney disease patients with metabolic acidosis?
I have always used sodium bicarbonate in this scenario. The easiest/cheapest way to prescribe it is to advise patients to use Arm & Hammer baking soda, which is essentially sodium bicarbonate. I gm of sodium bicarbonate provide 11.9 mEq of bicarbonate; therefore one half of a teaspoon (about 2.5 gm)...
Do you offer home administration of ESAs for your patients with anemia of chronic kidney disease?
Yes, it the patient's prescription drug plan allows it. Traditional Medicare does not allow home administration of ESAs since they are covered under part B rather than part D. However, many Medicare Advantage and commercial insurers do allow for home administration of ESAs, so I offer that option to...
How do you approach consults regarding clearance of patients with chronic kidney disease for surgery?
I never provide "clearance" for surgeries. I comment whether kidney disease is stable and whether there are any contraindications to surgery, medications, etc. based on the kidney disease.
How would you manage a patient with symptomatic Paget’s disease and osteoporosis who developed new fragility fractures while on Fosamax?
This is a complicated patient, and symptomatic Paget's needs more information. But given one wants to treat the Paget's and there are fragility fractures I would give an injection of Zoledronic Acid (mostly for the Paget's) and if needed, start Romosozumab for the fragility fractures. However, I wou...
When would you initiate chronic therapeutic phlebotomy in a patient with erythrocytosis secondary to a high hemoglobin-oxygen affinity hemoglobinopathy?
The large majority of patients with high oxygen affinity hemoglobinopathy do not require therapeutic phlebotomy. There is a subset of patients who develop symptoms (generally these are non-specific such as headache) or complications such as thrombosis. There seems to be no correlation between hemato...
Do you recommend lifelong antibiotic prophylaxis, or do you prefer a more selective approach based on risk factors in asplenic patients without a history of severe infections?
The advice is limited by the fact that there are no randomized controlled trials in adults on daily antibiotic prophylaxis post-splenectomy. There are trials in children with sickle-cell disease that do show a benefit, but it is not clear that these can be extrapolated to splenectomized adults. Furt...
Would you avoid SGLT2 inhibitors in patients with nephrostomy tubes?
I probably would unless a compelling reason to use. I worry about risk of infection and would imagine that depending on the reason for the nephrostomy tubes might limit the potential upside of using these agents. Maybe in future years as we gain more experience in non-study populations my answer wil...