Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach evaluation and management of a patient with recurrent monoarticular inflammatory arthritis of unclear etiology?
Routine testing will not identify Lyme disease although the WBC count is higher than usual. If the antibiotic does not target B burgdorferi recurrence might mean inappropriate therapy previously. WBC count WAAAY too high for mere trauma or internal derangement. Anything else to suggest psoriasis? Lo...
How do you approach mild prolactin elevations (20-80) in women with galactorrhea on nipple stimulation but regular menses and no plans for pregnancy?
I get baseline MRI of the sella and then monitor prolactin every 6-12 months. I don't treat unless the patient develops symptoms.
What is your approach to transitioning an SLE patient from a pregnancy incompatible regimen to pregnancy compatible regimen?
There are no clear data on how to do this. One study (Fischer-Betz et al., PMID 23382355) transitioned patients by reducing the MMF by 500mg/d dosing every four weeks and then stopping MMFo once the patient is down to MMF 500mg/d and adding azathioprine 2mg/kg. In my clinical practice, I taper faste...
What are some of the biggest challenges you run into when patients transition from pediatric to adult care?
Expectations – the pediatric health care system tends to have more resources readily available to assist patients (e.g., social work, child life, psychology, pharmacy) and appointment times tend to be longer. In the adult world, resources may be less readily available and appointment times shorter....
How do you manage significant asymptomatic indirect hyperbilirubinemia in patients with hemolytic diseases (SCD, HS, etc.)?
Hello, Indirect bilirubin is from hemolysis, not cholestasis (a few exceptions from rare syndromes), so not associated with stones, and would not expect ursodiol to help. It's a marker of how bad the sickling is - along with LDH, reticulocyte count, and MCHC (which measures cell density, i.e., irrev...
What is your approach to the workup for an underlying systemic condition in a patient presenting with retinal vasculitis?
Retinal vasculitis is a frequently misunderstood condition. My colleagues and I have written about it on several occasions such as in Current Opinion in Rheumatology, 2016. Retinal vasculitis is often diagnosed by an ophthalmologist on the basis of vascular leakage in a test called a fluorescein ang...
Should all kidney transplant patients be started on statin therapy post operatively given their increased risk of CVD?
A kidney transplant is not an indication for statin therapy per se. The 2018 cholesterol guidelines list CKD (but not ESRD or Transplant) as a risk-enhancing factor. I would guide the decision to use statin therapy based on the patient's risk as assessed for non-transplant patients. Having said that...
What lab markers are helpful for monitoring polymyalgia rheumatica patients on tocilizumab?
Based on the evidence supporting the use of tocilizumab (TOC) for the treatment of GCA, a number of small clinical trials have presented early data regarding its use for the treatment of PMR. Before we all jump on this bandwagon, we should carefully review the rationale for using TOC to treat PMR.Fi...
Do you recommend a daily B complex multivitamin for patients with end stage kidney disease who are receiving peritoneal dialysis?
When it comes to Vitamin management in my dialysis patients I defer to my RD, Diane Mettler, who has decades of experience and knows this material better than I ever will. Diane says “I recommend a daily renal vitamin on PD, due to the losses of B-vitamins with dialysis. That being said, if the pati...
How do you approach increasing urinary citrate levels in a patient with recurrent calcium nephrolithiasis who has hypocitraturia, non-acidic urine, and normal serum bicarbonate levels?
For the patient you describe, I would start Moonstone and monitor serum electrolytes and 24 hour supersaturation as I increase the Moonstone dose to optimize treatment. I have no financial interest in this product. Stephen B. Erickson, MD