Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there an age at which you consider not starting antifibrotic therapy in a patient with IPF?
I don't have an age cutoff. In my first couple of years of practice, I was hard-pressed to prescribe octogenarian antifibrotics, but I've come to think that approach is discriminatory.There does not appear to be an age at which antifibrotics lose efficacy. The real question seems to be whether older...
Do you consider administration of nintedanib or pirfenidone via enteral tube in patients unable to take PO due to recurrent aspiration?
I have not ordered nintedanib or pirfenidone via enteral tube for any of my patients. However, in the past, I have looked into it due to some research interests and have discussed it with our local MSLs and our clinical pharmacist. Nintedanib is available only in capsule form and is not recommended ...
Are there any contraindications to starting a patient on Dupixent for prurigo nodularis if the patient is already on Xolair for asthma?
No, and in fact, I have this combination in several patients.
Can combined oral contraceptive use cause falsely elevated 24-hour urine-free cortisol?
UFC is an expression of free cortisol. It should not be affected by oral estrogen.
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.