Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach a young patient with bilateral lower extremity muscle weakness and positive anti-Smith, dsDNA, RNP, Raynaud’s, and pericardial effusion but normal muscle enzymes?
The timeline of weakness may be helpful, but another possible cause of weakness in the setting of normal CK would be an inflammatory demyelinating polyneuropathy (can be acute or chronic). EMG and NCS would be helpful in evaluating this.
What is your approach to patients with advanced chronic kidney disease who are taking aluminum containing medications?
If taking infrequently would not be all that concerned although there are other options available. Would instruct them to avoid citrate-containing medications such as Bicitra due to their enhancing Al absorption from the GI tract.
What is your approach to management of hyperlipidemia in patients taking JAK inhibitors?
The ORAL Surveillance Study published in the NEJM in 2022 was a phase IIIb/IV open-label noninferiority study in RA patients over the age of 50 with at least one cardiovascular risk factor. The aim was to demonstrate that JAK inhibitors were non-inferior in terms of major adverse cardiovascular even...
Do you recommend the use of GLP1 R agonist therapy in patients with T1DM for weight loss?
GLP-1 agonists can be used as off-label in patients with Type 1 DM and obesity to help with weight loss; improve Hb A1c and decrease insulin requirements.A meta-analysis by Tan et al., PMID 38249345 of 11 RCT comprising 2,856 patients with Type 1 Diabetes and the use of GLP1 agonists as an adjunctiv...
Do you recommend parathyroid adenoma resection or ablation for patients with primary hyperparathyroidism and recurrent nephrolithiasis who are found to have a single gland adenoma on parathyroid ultrasound and nuclear medicine imaging?
Yes. My two indications for ablation/resection of a proven parathyroid adenoma are (1) metabolically active calcium-based kidney stone disease and/or (2) osteopenia/porosis as identified by bone scan. I think there is strong evidence that primary hyperparathyroidism can cause either or both. In the ...
Do you use oral fosfomycin as a treatment option for uncomplicated cystitis due to ESBL producing E coli?
Fosfomycin is one of the first-line drugs for uncomplicated UTI listed in the Infectious Diseases Society of America (IDSA) UTI treatment guidelines (these guidelines are currently being updated). It is the only single-dose drug approved for UTI and is an effective option. It does have activity agai...
When treating pancreatic body/tail lesions that result in significant dose spread to the spleen, what is your threshold to offer pneumococcal, hemophilus influenza, and meningococcal vaccines?
A really great question, and one that we don’t necessarily have a lot of data for guidance. There are some guidelines out there, though, that I think can be helpful to consider. The first is the recent guideline from ASCO on the vaccination of adults with cancer (Kamboj et al., PMID 38498792). In li...
Would you recommend cinacalcet for patients with recurrent nephrolithiasis who have hypercalciuria despite thiazide diuretic use and who also have an elevated PTH level without localizing parathyroid adenoma on imaging?
This is a tricky question with a nuanced answer. If the hyperparathyroidism is secondary, cinacalcet may have a role in treatment along with normalizing serum phosphorus and vitamin D. However, metabolically active kidney stones are unusual in advanced chronic kidney disease. If the hyperparathyroid...
Do you use the peri-operative management of biologics and DMARDs guidelines, which were mainly based on total hip and knee replacement surgeries, for all peri-operative surgical management?
The American College of Rheumatology Perioperative Guidelines focused on patients undergoing hip or knee arthroplasty. These guidelines can be a helpful starting place when thinking about medication management in patients undergoing other surgeries, but my recommendations for perioperative managemen...
Do you use asthma or EoE dosing if initiating dupilumab in a patient who meets criteria for treatment for both disorders?
I would do the higher dose (EoE) if starting it for both.