Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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.
How do you approach the timing of DMARD initiation in patients with active RA who are on treatment for latent TB?
As the patient is already treated for latent TB, if they have not initiated DMARD therapy for RA, I would follow the guidelines and start conventional DMARD therapy. If the patient requires additional therapy because of insufficient response, I would choose a non-TNF inhibitor as the risk for TB rea...
Is omalizumab an option for a patient needing a specific antibiotic with an IgE-mediated reaction who continues to have reactions during a desensitization?
Omalizumab is FDA-approved for Asthma, Chronic spontaneous urticaria, chronic rhinosinusitis with nasal polyposis, and food allergy. It is a monoclonal antibody directed at IgE which will deplete circulating IgE and thus specific IgE on the mast cell and basophils will decrease. There is also likely...
How do you approach the management of persistent hyperphosphatemia in ESKD patients who are non-adherent to phosphate binders?
This is not easy. The first thing I usually do is try and find out why they are non-adherent. Is it due to side effects, cost, etc? Are there social reasons? For example, are they "embarrassed" to take binders if they are out eating with friends? Often, I find that I need to switch binders to see if...
What is the current recommendation for air travel after a primary spontaneous pneumothorax?
General guidelines including the British Thoracic Society recommend delaying air travel for at least 2 weeks following the radiographic resolution of a pneumothorax. However, recent studies have challenged this conservative approach. A study by Majercik et al., PMID 25494425 demonstrated that patien...
What are your management strategies for patients with recurrent nephrolithiasis and hypercalciuria who develop hypercalcemia after thiazide initiation?
My first concern is why. The thiazide may have unmasked primary hyperparathyroidism. I would get a PTH level plus serum phosphorus and vitamin D with a concurrent serum calcium to see if they are concordant. If not, it’s time to image the parathyroids. If no evidence of hyperparathyroidism, and hype...
Do you utilize urinary leukotrienes as a marker for initiation of montelukast?
No, I don’t. It is not readily available clinically and has not been shown to be predictive of response.
Do you recommend avoidance of vaginal estrogen in patients with SLE?
It depends on the age. The SELENA study demonstrated that BCPs in premenopausal women did not lead to flares or increased disease activity though the risk of increased clotting is an issue for APL+ folks. Post-menopausal women treated with HRT had an increase in mild flares compared to those not on ...