Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When do you start bisphosphonates empirically, irrespective of DEXA results, in patients going on chronic glucocorticoids?
I think this is an important question. I personally got really interested in bone in large part because of all the glucocorticoids that I was using to treat serious inflammatory diseases. I was fortunate to spend time with Dr. Howard Polley from Mayo when I was a fellow. He was on the team that gave...
Can romosozumab be used in patients on dialysis?
This is an interesting question given the common finding of osteoporosis among patients undergoing hemodialysis. There have been several individual case reports suggesting that treatment with romosozumab in this patient population can be safe and effective. The largest study (no control group) of wh...
What is your approach to practical monitoring of lupus disease activity in clinical practice?
ANSWER TO QUESTION 1:I am so glad I am being asked this question!I use my clinical assessment (or physician global assessment).I generally love the 2023 EULAR SLE management update (Fanouriakis et al., PMID 37827694). However, I disagree with their recommendation that clinicians monitor the SLEDAI (...
How do you adjust your HbA1c goal for managing diabetes in elderly patients with multiple chronic illnesses but no limitations in performing self-care tasks?
There is guidance from ADA, AACE and other organizations. Most agree that an A1c target of 8% is perfectly acceptable in advanced elders and/or people with multiple comorbidities and limited life expectancies. The critical issue is to understand what a reasonable timeline for the patient is. The nat...
What is your preferred rate control agent for atrial fibrillation with rapid ventricular rate, and why?
It really depends on the clinical scenario. My preferred first line agent is short acting metoprolol. Non-dihydropyridine calcium channel blockers such as diltiazem or verapamil are also effective but should generally be avoided in patients with reduced LVEF. In hospitalized patients with tenuous he...
What is your approach to patients with recurrent nephrolithiasis and hypercalciuria who are unable to tolerate thiazide diuretics due to hyperglycemia?
I think it is a risk-benefit analysis. The answer depends on the severity of the stone disease and the severity of the hyperglycemia. Obviously, controlling hyperglycemia would have multiple benefits, and I would certainly proceed along that route. But if the calcium-based kidney stone disease is se...
What is the management strategy for patients who develop AKI and nephrotic range proteinuria secondary to biopsy proven FSGS during immune checkpoint inhibitor therapy?
For glomerulonephritis induced by ICI would recommend rituximab 1 gram for a total dose of 2 doses 2 weeks apart. Based on limited case reports there has been a good response to rituximab with maintained remission of glomerulonephritis and the ability to continue on ICI without relapse. Please refer...
What recommendations do you offer for patients who have nail longitudinal ridging?
Nail longitudinal ridging is also called onychorrhexis. Onychorrhexis may become more prominent with age and is a diagnostic feature of brittle nail syndrome, along with onychoschizia, or nail peeling. For onychorrhexis, I recommend moisturizers around the nailfolds, clear nail protectants to the na...
How do you manage unintended hypercalciuria that results from an increase in dietary calcium intake as recommended to patients with recurrent calcium oxalate nephrolithiasis attributed to enteric hyperoxaluria?
I find this to be a common concern. As you know, the idea of treating enteric hyperoxaluria with supplemental oral calcium is to bind dietary oxalate in the gut before it can be absorbed systematically. In addition to arranging an appointment with our stone clinic (not general) dietitian to discuss...
Would you transition from IV to oral antibiotics in a solid organ transplant recipient with uncomplicated gram-negative bacteremia?
Yes, I would in the right circumstances. The referenced article by Nussbaum et al., PMID 38195100 provides reasonable evidence that this is a valid approach. Particularly, if the patient's net-state-of-immunosuppression is not terribly high and the organism is susceptible to highly bioavailable oral...