Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage patients with SLE undergoing assisted reproductive therapy with estrogenic effects?
For patients undergoing any form of assisted reproductive technology (ART), it is important to assess their SLE disease activity. If a patient has moderate to severe SLE disease, I recommend delaying ART until we have better control of their disease. Once we plan to move forward with ART, I check an...
What is your approach to managing hypokalemia in patients with Bartter syndrome who are on high doses of potassium chloride but cannot tolerate amiloride or ACEi/ARBs due to low blood pressures?
Since prostaglandin level is typically high in patients with Bartter syndrome, NSAIDS can be tried to treat hypokalemia in these patients who cannot tolerate amiloride or ACEi/ARB due to low blood pressure. However, close monitoring of renal function is required if NSAIDS were to be given in these p...
Do you recommend IM Kenalog injection for refractory CRSwNP in a patient already on maximal therapy?
For refractory CRSwP on maximal therapy, IM Kenalog would not be my drug of choice. I would rather suggest Dupixent. A number of published papers including some from Klaus Bachert clearly show the benefit of Dupixent in this subgroup of patients. IM kenalog might help for a short time, but Dupixent ...
For hypogammaglobulinemia as a complication of successful treatment, do you empirically start prophylaxis with either 400 mg/kg monthly for IVIG or 100 mg/kg weekly for subcutaneous immune globulin?
Most of the data to support IVIG for hypogam comes from CLL literature. Data in those post-transplant and post-CAR T are limited. IVIG has a reputation of being a bit of a panacea, but I challenge that notion. We investigated the implementation of an IVIG stewardship plan to limit IVIG usage just fo...
Do you continue methotrexate in patients with inflammatory arthritis who develop non-melanomatous skin cancer while on therapy?
Data on methotrexate use and the increased risk of non-melanomatous skin cancers has been conflicting, suggesting an increased risk or a neutral risk. A recent case-control study published in the British Journal of Cancer (Polesie et al., PMID 36739322) did suggest an increased risk of both squamous...
Can transudative pleural effusions lead to trapped lung?
Yes. I’ve seen it many times especially in patients with longstanding CHF and/or CKD. With a persistent effusion of any type, the pleura can respond by forming a peel resulting in a non expanding lung.
If prompted as an outpatient, how do you counsel patients on the rare cardiac complications of vaccinations including myocarditis?
Not a common event so the incidence is low and depends on patient exposure as to why getting vaccinated in the first place and always a good idea to discuss the risks and benefits of vaccination.
When is the best time to consider left atrial appendage closure for secondary stroke prevention in patients with atrial fibrillation?
There is equipoise about the timing of left atrial appendage closure following ischemic stroke. Due to the need to temporarily treat a patient with either dual antiplatelet or anticoagulation therapy, it is reasonable to wait until after the acute stroke period has passed to allow for healing of inf...
Should GLP-1 agonists be weaned in patients who have achieved goal weight loss and glycemic control?
This is a good question that comes up often. The short answer is no -- GLP-1 receptor agonists should not be weaned after achieving goals. There are several trials where GLP-1RA has been discontinued after 6 or more months of therapy and weight regain is substantial on average and the loss of glycem...
Do you utilize serial MRI imaging in patients with axial spondyloarthritis to ensure good disease control or do you rely on symptoms and physical exam to assess treatment response?
The ACR 2019 guidelines recommend that MRI could provide useful information in cases where the level of disease activity was unclear and where this information would influence treatment decisions. For patients with nr-axSpA, the imaging should focus on the sacroiliac joints. In interpreting MRI resu...