Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Does hepatitis B vaccination reduce the risk of HBV reactivation associated with immunosuppressive therapy?
Hepatitis B reactivation is a critical concern when patients are undergoing immunosuppressive therapy, often described as 'deadly but preventable.' Screening for HBV is strongly advised before initiating biologic therapies, targeted synthetic therapies, or high-dose immunosuppression, including HBsA...
What is your approach to managing hyperkalemia in pregnant patients with chronic kidney disease?
Have to look at entire renal panel Address - HCO3 if very low as hyperkalemia may be due to shifting Evaluate other med (i.e. heparin) and dietary intake Assess volume status Consider fluid bolus + dose of loop diuretic
What is your approach to managing patients with labile blood pressures secondary to baroreflex failure?
Managing BP in the setting of baroreflex failure or dysautonomia is challenging. It is sometimes helpful to educate patients on realistic expectations. Medications will not be able to replace the baroreflex function. Conservative measures like compression socks during the day, bathroom modifications...
What would be your next step in management of a dermatomyositis patient on hydroxychloroquine and methotrexate whose skin is still active?
There are many different options for this kind of scenario. Depending on the physician's preference, patient's lifestyle, and insurance coverage, one could switch to mycophenolate, which seems to be more effective for skin manifestations, or azathioprine. If the patient did have a partial response t...
What immunosuppressive agents would be available to patients with a history of melanoma?
Generally, we try to use conventional synthetic DMARDs when possible. However, studies in RA have not shown an increase in de novo melanoma or recurrence of cancers more generally with TNF-inhibitors. So this is an option for patients with RA and melanoma history who are not responding to csDMARDs. ...
Do you generally prefer to continue hydroxychloroquine in lupus patients who develop ESRD despite the low likelihood of clinically active disease in this patient population?
Yes, I do. In my experience, nephrologists tend to forget or neglect the use of HCQ. HCQ can prevent lupus flare-ups and progression of disease not to mention CV benefits as well as being helpful in addressing APS if present.
How do you choose between antithyroid drugs, RAI, and surgery for hyperthyroidism patients with existing cardiovascular disease, given their varying effects on cardiovascular outcomes?
This recent JAMA study (Chiung-Hui Peng et al., PMID 38436957), and others like it (e.g., Okosieme et al., PMID 30827829) show higher mortality rates and CV disease in patients receiving ATDs vs RAI, or better outcomes with surgery vs both RAI and ATDs (Liu et al., PMID 35822337). The main reason ap...
What is your recommended dosing regimen for propranolol in treating an infantile hemangioma after the proliferative phase?
Generally, in most infants/toddlers that have infantile hemangiomas that are already in the involution phase, I do not start propranolol, but rather wait until the end of the involution phase and then consider PDL or surgery if needed, based on the location/size/appearance of the residual lesion. Pr...
Do you recommend a patient with recurrent nephrolithiasis who is performing a 24 hour urine collection add a urine preservative or keep the specimen refrigerated?
We always add a preservative that will not interfere with any of the analytes to be measured. Additionally, we recommend refrigeration of the specimen. Stephen B Erickson, MD
How do you approach management for CCUS with severe cytopenias?
This is a very timely question since CCUS is now much better defined. CCUS (Clonal cytopenia of undetermined significance) is not a new syndrome, it is a subset of myelodysplasia (MDS), both of which as late as 1983, were actually known as: "Preleukemia". CCUS is an uncommon form of MDS, which has v...