Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What would be your recommendation for treatment of worsening lung disease in a patient with long-standing scleroderma after long-term mycophenolate therapy which is no longer an option due to side effect/intolerance?
Someone who has been on long-term Mycophenolate for interstitial lung disease and has had stabilization or improvement in their lung function and then is unable to tolerate the medication may be able to be switched to mycophenolic acid sodium (myfortic) which is often less toxic and better able to b...
How do you approach medication management in patients with RA when transitioning from csDMARD triple therapy to anti-TNF?
There is not a one-size-fits-all approach to this question. Drug transitions can be influenced by several factors including individual side effects of medications, patient preference for other reasons, disease co-morbidities, ability to use prednisone as bridge therapy, etc. In general, hydroxychlor...
Would you consider lifelong versus short-term (i.e. several months) course of anticoagulation for patients with elevated CHADSVASc score presenting with newly diagnosed paroxysmal atrial fibrillation triggered in the setting of acute illness (i.e. tachyarrhythmias with COVID-19 or bacterial pneumonia)?
AF during an acute illness could result from the stress of an infection, however, these patients do seem to be at higher risk of recurrence. It might also simply represent the first time that AF has been recognized in a patient who is at risk for atrial arrhythmias. Anticoagulation is indicated in t...
Is reduction in proteinuria with SGLT2i dose dependent?
My understanding of dosing with empagliflozin, in particular, is that it is not dose-dependent, thus a dose of 10 mg versus 25 mg will lead to a similar reduction in proteinuria. This is based on data from the EMPA REG OUTCOME trial published in NEJM in 2016. The composite outcome of incident or wor...
Should thyroxine hormone be started in women having fertility concerns with high-normal TSH and negative TPO antibody?
This landmark NEJM trial showed no benefit in women with TPO antibodies and a TSH > 2.5 of starting levothyroxine. However, most IVF centers start low-dose levothyroxine since subclinical hypothyroidism is associated with an increased risk of miscarriages especially if TSH > 5 or TSH > 2.5 with posi...
Would you stop azathioprine in a patient with ANCA vasculitis who has been in long term remission on azathioprine, but has a new diagnosis of lung cancer requiring initiation of immunotherapy?
Data about the effect of immunosuppression on the efficacy of immune checkpoint inhibitors suggests that there is a negative of effect of being on immunosuppression at the time of ICI initiation on tumor response. So if the patient really has been clinically stable for a long time there are a few op...
Is there a kidney length for which you would no longer recommend attempting a kidney biopsy due to safety concerns and lack of diagnostic yield?
Yes. I definitely do not biopsy very small kidneys. Where you draw the line is the question. I think it is not only the size of the kidney but also the height of the patient. It may be OK to biopsy a patient with a 7.5 cm kidney who is 4 feet 8 but not OK to biopsy an 8 cm kidney in a patient who is...
Do progesterone only oral contraceptive pills affect cortisol binding globulin?
I do not recall any recent publications, but I am sure old studies have examined this question. Based on my clinical experience, there is no significant effect on total cortisol levels.
What is your treatment algorithm for managing porokeratosis?
Porokeratoses do not necessarily require treatment unless desired by the patient for symptomatic or cosmetic reasons. At minimum, I counsel on the increased risk of squamous cell carcinoma within the lesion and recommend sun protection. If treatment is desired, cryotherapy, topical retinoids, imiqui...
What 60 minute cortisol threshold value do you use for diagnosis of adrenal insufficiency after ACTH stimulation?
It depends on the assay. Different assays measure different things. Mass spectrometry is the most accurate available assay at present, and it measures ONLY cortisol. Immunoassays also detect other related compounds, and vary from assay to assay as to which ones. Discussed in PMID 25877990.