Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach hypocomplementemia in Sjogren’s without features of lymphoma?
Low C3 and/or C4 support immune activity. Therefore, I look at all domains that SjD can potentially affect for further clues. Low complements in SjD are associated with systemic disease activity (Ramos-Casals et al., PMID 24162151). Low C4 may suggest a more severe disease (Pavlakis et al., PMID 223...
What strategies do you employ for adjusting the dosage of levothyroxine in hypothyroid patients who experience significant weight loss or are initiated on GLP-1 receptor agonists?
In spite of significant weight loss, some patients may not require a dosage change for levothyroxine while others may require a dosage reduction. It is very reasonable to recheck a TSH with free T4 after a 10% weight loss to see if a dose adjustment is needed. Rapid weight loss may lead to a tempora...
When would you consider obtaining a cardiac CT in lieu of standard TEE for the detection of a left atrial appendage thrombus in atrial fibrillation?
TEE is still the gold standard for the evaluation of left atrial appendage thrombus. That being said, there is certainly a role for cardiac CT as well, especially in patients with esophageal pathology or other conditions that increase the risk or contraindicate the use of TEE such as significant thr...
How would you approach medication de-escalation in a patient with a history of rapidly progressive CTD-ILD who responded to and is currently on mycophenolate 3 grams daily and IVIG 2mg/kg monthly infusions and has been stable for two years?
This is an excellent question with the very little data to go by. We spend most of our time studying escalation of therapy and very little time discussing de-escalation. It has been my experience as a rheumatologist for almost 37 years that many autoimmune diseases initially can be quite immunologic...
How do you approach management of a patient with idiopathic PAH and +ANA, but no other current symptoms/signs of active rheumatologic disease?
(1) Of note, abnormal nail fold capillaroscopy is associated with PAH in several systemic immune diseases: This is famously true for systemic sclerosis, but there are also publications reporting this association for other diseases, notably those in the “lupus family“ like SLE and dermatomyositis. As...
How do you apply the 2HELPS2B score into clinical decision making for determining duration of cEEG testing?
I think there are two important issues to note: Always remember that the study was based on a 1-hour screening EEG, not a typical 20-minute routine. This may or may not make a difference in finding sporadic epileptiform abnormalities or BIRDs. Most of the time you do not need to use this score. Fo...
In which patients do you prefer daily standard three-drug therapy for non-cavitary pulmonary MAC as opposed to three times a week dosing?
Generally, if non-cavitary disease I favor thrice weekly therapy. However, if widespread non cavitary disease or immunosuppressed, I may choose daily dosing.
Do you consider the use of antifibrotics at presentation in patients with a radiographic UIP pattern of pulmonary fibrosis in the presence of positive serologies without any symptoms of CTD who have not yet demonstrated evidence of a progressive phenotype?
I really like this question, because it succinctly encapsulates several areas of clinical uncertainty that we are routinely forced to address in our ILD clinics! Let’s unravel some of the subtleties here. For starters, if the radiographic pattern is convincingly that of UIP, our patient will technic...
Do you prefer starting a SGLT2i before steroids in patients with IgA nephropathy and proteinuria > 1.0 gram/day who are unable to tolerate ACEi/ARB due to hypotension?
I do try to start almost all of my IgAN patients on ACE-I/ARB and SGLT2i to help decrease proteinuria. The decision to start steroids or any other immunosuppressive treatment does not always have to wait for 6 months of conservative treatment and if still with residual proteinuria, then consider imm...
For patients with metabolic syndrome, is it reasonable to wait for the effect of tirzepatide therapy on their lipid profile prior to starting statin therapy?
While tirzepatide has shown significant improvements in lipid profiles, including reductions in total cholesterol, LDL cholesterol, and triglycerides, and increases in HDL cholesterol, these effects should be considered complementary to, rather than a replacement for, statin therapy.