Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend repeat kidney stone composition testing for a patient with recurrent nephrolithiasis who passed an additional stone but previously already had stone composition testing performed?
Good question. Certainly, if there has been a gap in stone events prior to new development of stones, it is reasonable to confirm both the stone composition and the 24-hour urine chemistry, to see if conditions have changed in a meaningful way. It would be less important, if the patient had regular ...
Is the phosphorus-lowering benefit of patiromer compelling enough to switch a patient with chronic hyperkalemia and hyperphosphatemia from sodium zirconium cyclosilicate to patiromer?
I don't think so but I think Patiromer is a better agent anyway as it does not have sodium in it. Patients with CKD and especially dialysis patients are often volume overloaded. It definitely makes sense to use an agent that does not have sodium in it.
How do you titrate lithium for patients with bipolar affective disorder during pregnancy and immediately after delivery in the context of fluid shifts and changing levels?
Great question! Lithium clearance increases during pregnancy, and some women may require a dose increase to maintain therapeutic benefits. It is not my practice to prophylactically increase the dose during pregnancy, but I do recommend monitoring labs (lithium level, BUN and creatinine, and TSH) ea...
Would you treat a patient for heterotopic ossification prophylaxis if >72 hours after surgery?
RT is very effective in reducing heterotopic ossification that can happen after surgery/trauma to the hips. We have always been taught to do either before 24 or less before surgery or within 72 hours after surgery. The rationale is that RT prevents HO by the inhibition of osteoprogenitor cells proli...
How long do you monitor proteinuria after starting an SGLT-2 inhibitor before considering adding another medication if proteinuria is not at goal?
I would typically wait 2-3 months. Most such patients should be on RAAS blockade which should be maximized if tolerated first.
At what point should aspirin therapy for stable cardiovascular disease be discontinued in patients with a diagnosis of chronic cerebral microbleeds or possible Cerebral Amyloid Angiopathy?
I would continue low aspirin indefinitely.
How soon after an end stage kidney disease patient receives a MRI study with gadolinium contrast do you perform their next hemodialysis session?
Very contentious question. But as an author of the NKF and ARA position paper on this, I would follow our advice, no need to dialyze immediately after, but try to time the study with the next dialysis.Weinreb et al., PMID 33170103ASN Communities (for ASN members) had a VERY LONG post on this general...
What treatment options would you consider for a young patient with limited mobility, low bone mass and multiple vertebral compression fractures who is on dialysis for advanced kidney disease?
There are a lot of variables to this question. I would worry that the person may have a variant of OI (osteogenesis imperfecta) or some other collage problem and then add renal failure to the mix. I would try to establish the causes of each problem first such as steroid induced bone disease or a bon...
For patients with essential thrombocythemia already on prophylactic dose DOACs, do you defer starting aspirin?
I usually defer aspirin in these situations. There is evidence from PV that aspirin plus anticoagulation increases bleeding risk (Zwicker et al., PMID 34162181). If an ET patient has a high-risk disease with prior arterial thrombosis, then I would favor adding aspirin.
Do you routinely recommend doxycycline for pregnant individuals with rickettsial diseases despite the historical concern for side effects in pregnancy?
It has been known for years that short courses (<3 weeks) of doxycycline are safe in pregnancy and in young children. This article just reinforces the recommendations. Rickettsial diseases have significant morbidity and mortality and should be treated with the best (and best proven) antimicrobial. T...