Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to management of hyperlipidemia in patients taking JAK inhibitors?
The ORAL Surveillance Study published in the NEJM in 2022 was a phase IIIb/IV open-label noninferiority study in RA patients over the age of 50 with at least one cardiovascular risk factor. The aim was to demonstrate that JAK inhibitors were non-inferior in terms of major adverse cardiovascular even...
Do you recommend the use of GLP1 R agonist therapy in patients with T1DM for weight loss?
GLP-1 agonists can be used as off-label in patients with Type 1 DM and obesity to help with weight loss; improve Hb A1c and decrease insulin requirements.A meta-analysis by Tan et al., PMID 38249345 of 11 RCT comprising 2,856 patients with Type 1 Diabetes and the use of GLP1 agonists as an adjunctiv...
Do you recommend parathyroid adenoma resection or ablation for patients with primary hyperparathyroidism and recurrent nephrolithiasis who are found to have a single gland adenoma on parathyroid ultrasound and nuclear medicine imaging?
Yes. My two indications for ablation/resection of a proven parathyroid adenoma are (1) metabolically active calcium-based kidney stone disease and/or (2) osteopenia/porosis as identified by bone scan. I think there is strong evidence that primary hyperparathyroidism can cause either or both. In the ...
Do you use oral fosfomycin as a treatment option for uncomplicated cystitis due to ESBL producing E coli?
Fosfomycin is one of the first-line drugs for uncomplicated UTI listed in the Infectious Diseases Society of America (IDSA) UTI treatment guidelines (these guidelines are currently being updated). It is the only single-dose drug approved for UTI and is an effective option. It does have activity agai...
When treating pancreatic body/tail lesions that result in significant dose spread to the spleen, what is your threshold to offer pneumococcal, hemophilus influenza, and meningococcal vaccines?
A really great question, and one that we don’t necessarily have a lot of data for guidance. There are some guidelines out there, though, that I think can be helpful to consider. The first is the recent guideline from ASCO on the vaccination of adults with cancer (Kamboj et al., PMID 38498792). In li...
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...