Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you use amyloid lowering therapy in patients on chronic anticoagulation?
I wouldn’t feel comfortable doing this because of the elevated risk of ARIA-H. The Alzheimer’s Association Therapeutics Work Group advised that patients receiving anticoagulants should not be offered lecanemab (Cummings et al., PMID 37357276).
What is your approach to genetic counseling prior to obtaining genetic testing in young asymptomatic patients suspected of having autosomal dominant polycystic kidney disease?
If you feel comfortable, a nephrologist who sees a lot of PKD patients is usually capable of doing the counseling. For me, I discuss the pros and cons and alternatives to genetics testing such as imaging, which has limitations at young ages, and considering blood pressure monitoring and other genera...
For patient with polycystic kidney disease and proteinuria who are on maximum dose of ACEi/ARB, what are other anti-proteinuric medications that should be considered?
This is a great question because it highlights that patients with ADPKD should have proteinuria worked up as with any other patient with CKD - sometimes even by biopsy if needed (if tissue can be obtained safely, usually requiring urology and possibly using laparoscopic approach if ultrasound is not...
Do you combine methotrexate and leflunomide for the treatment of RA?
Absolutely! What a coincidence, as I was just communicating by email with a patient with horrible hard-to-control psoriatic arthritis (PsA) who failed numerous combos and biologics. (I know this question is RA, but also think of LEF with PsA). It was not until I added leflunomide (LEF) to her regime...
Is your decision to prescribe empagliflozin for CKD patients without albuminuria influenced by a recent cost-utility analysis showing that empagliflozin was not cost-effective for this group?
I have not been in the habit of prescribing these medications in the absence of proteinuria.
Do you recommend patients with chronic kidney disease avoid supplements containing creatine?
I do not have patients necessarily avoid these supplements. I do advise with supplements in general we don't always know what else is in the supplement and how supplements interact with each other and prescribed medications.
What is your approach to establishing a dry weight in a pregnant patient with ESKD on hemodialysis given the expectation of weight increase and pregnancy-related edema?
I think there is a lot of nuance managing weight in pregnant patients with ESRD. Pregnant patients have better fetal and maternal outcomes when clearance is increased. Outcomes are best with >36 hours of dialysis per week. Adjustment of dry weight should include assessment of volume status, blood pr...
When transitioning from anabolic agent to denosumab, do you stop teriparatide 1 day prior to transition and romosozumab 1 month prior to transition?
I do not believe there is any comparison data to guide this question. My philosophy was to get denosumab going asap at the end of our scheduled anabolic course. I would often schedule a tptd or abaloparatide patient at 23 months to discuss denosumab and get the process started for approval. We often...
What range of musculoskeletal complaints have you seen with romosozumab use?
The most common side effect with Romo is injection site reactions. Some patients may have musculoskeletal pain but so do many patients not on Romo. Overall, I found that it is very well tolerated, but if a patient believes that it is causing major undesirable effects, then it is probably best to sto...
How do you approach immunosuppression in patients with a positive Interferon Gamma Release Assay and prior intravesicular BCG treatment for bladder cancer?
Bacillus Calmette–Guérin (BCG) is the most widely used vaccine worldwide and has been used to prevent tuberculosis for a century. BCG also stimulates an anti-tumor immune response, which urologists have harnessed for the treatment of non-muscle-invasive bladder cancer. As rheumatologists, we occasio...