Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you routinely transition patients with recurrent calcium based kidney stones off of hydrochlorothiazide and onto chlorthalidone or indapamide for optimal control of hypercalciuria?
Yes, I do as they are longer acting thiazides and thus have better control over hypercalciuria. I generally start with Indapamide 1.25 mg daily and will titrate up if necessary. I prefer that as opposed to Chlorthalidone as to start with 12.5 mg Chlorthalidone, you need to cut it in half, which is n...
How would you manage a patient with SLE that has a remote history of positive anti-phospholipid antibodies with a current DVT and now completely negative APLs?
Assuming the reliability of the lab report indicating negative antiphospholipid antibodies (APL) and the absence of any other manifestations as per the latest APLS guidelines, I generally would not factor a distant history of APL positivity when determining the management of this patient.While the f...
Would you treat an ESKD patient with renal artery stenosis in an attempt to improve blood pressure control and preserve residual renal function?
When a patient is dialyzing, the dialysis prescription and lifestyle factors, like salt and water intake, dominate blood pressure control. In both CORAL and ASTRAL trials, blood pressure control and residual renal function was not improved by renal artery intervention. For both of those reasons, I w...
Would you continue Jak inhibitor therapy in a patient with long standing, previously refractory RA in their 60s who was found to have stenosis of the left common femoral artery and no other history of arteriosclerotic disease?
The concern for the use of Jak kinase inhibitors in RA patients over the age of 65 with at least one risk factor for cardiovascular disease comes from the Oral Surveillance Trial published in the NEJM in 2022. It is randomized, open-label non-inferiority study comparing cardiovascular safety (and ma...
Do you advise patients to hold DMARDs for conditions such as psoriasis or rheumatoid arthritis while actively undergoing radiation treatment?
Data in this setting is limited. I have usually not held DMARDs with RT unless treating with concurrent chemo RT or treating a site (pelvis) where myelosuppression caused by RT would further suppression immunity especially with biologics and methotrexate.
What is the best treatment for treatment resistant restless leg syndrome?
In general, when a condition is considered “treatment resistant”, it is useful to reconsider the diagnosis, assess the quality of the patient-doctor relationship, identify potential sources of treatment resistance, and identify multiple non-pharmacological approaches to addressing symptoms.
How long should T3 be continued in hypothyroid patients who received no symptomatic benefit after starting T3/T4 combination therapy?
I stop at next visit and increase T4 replacement accordingly.
What duration of therapy do you recommend for patients with a vascular graft infection in which the graft has been removed and another graft placed in the infected space?
The duration of antibiotics would also depend on whether the patient had positive blood cultures. At the time that a new graft is placed, graft site cultures should be obtained. This is because the patient may have received antibiotics prior to the procedure for a period of time. It is helpful to ha...
What therapies have you found most helpful for recalcitrant non-infectious cases of folliculitis?
In my experience, noninfectious folliculitis can be complicated by superficial infections with skin organisms, herpes, or fungi so treatment will include a topical anti-microbial. The folliculitis can be triggered by fragrances in laundry products, irritation by coarse fabrics or occlusion. The prim...
Does the presence of osteoporosis change the extent of workup that should be performed for an older patient with otherwise serologically low-risk MGUS?
In brief - no, it shouldn't. While some previous studies have suggested that patients with MGUS are more likely to develop osteoporosis than those who don't, this is often related to confounders when MGUS is picked up clinically - in other words, patients with comorbidities that prompt a doctor to l...