Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In patients with lupus nephritis on maintenance therapy, is there additional benefit in utilizing 2 grams vs 3 grams of mycophenolate mofetil (MMF) daily?
I agree with @Dr. First Last's answer. A few nuances to add: In my patients of African Ancestry, I always start with 1.5 gm bid if tolerated as they tend to need a higher dose (probably related to lower enterohepatic circulation, more rapid mycophenolic acid clearance, and other metabolic mechanism...
Are there clinical circumstances in which there is a role for steroids in treatment of calcified neurocysticercosis associated with perilesional edema and seizures?
Yes. Steroids would be routinely used if his perilesional edema. The question presumes that all of the intracranial lesions are calcified but there can be intraparenchymal cysts in different stages of dying or calcification.
What work-up should be considered in patients with significantly worsening A1c despite steady diet, lifestyle, and medication adherence?
For patients with unexpected decompensation in glycemic control, I would start off by ensuring that their fingerstick or CGM glucose data correlates with their rising A1c. New medications (such as immunosuppressants or protease inhibitors) and anemia can falsely elevate A1c. I would then make sure t...
How do you treat sarcoidosis associated hypercalcemia in a patient with adenopathy and no other signs of systemic involvement?
This may seem like a straightforward query, but like many issues surrounding sarcoidosis, it is actually deceptively complex. For a more complete discussion, I refer the readers to an excellent review by Lower and Saidenberg-Kermanac’h (2019). In and of itself, asymptomatic “mild” hypercalcemia does...
Do you always comment on VA and KCO when reading PFT's when gas transfer is ordered?
I do not. I look at the VA to see if it meets ATS criteria ( [1] >=90% of largest VC in the session; or >=85% and within 200cc or 5% of the largest VC; [2] breath hold of 10 +/- 2 sec; [3] >=85% of inh ventilation inhaled in <4sec)
How do you counsel patients on the side effects of sodium phenylbutyrate and taurursodiol?
I explain that the trial suggested that this medication is generally safe and well tolerated. As it says in the package insert "the most common adverse reactions (at least 15% and at least 5% greater than placebo) with RELYVRIO were diarrhea, abdominal pain, nausea, and upper respiratory tract infec...
Are there specific recreational activities or exercises you recommend patients with ankylosing spondylitis avoid?
The answer to this question depends on the severity of ankylosing spondylitis in the individual patient. The disease can manifest as sacroiliitis alone or total ankylosis from the sacrum to the cervical spine. The recommendations are different for those with limited disease versus extensive involvem...
Do you avoid empagliflozin in patients with history of amputation?
To be clear, you can prescribe any SGLT2i to a patient with an amputation or at high risk for an amputation due to prior foot ulcers, insensate foot, peripheral vascular disease. The "warning" (not contraindication) in the canagliflozin PI is "Consider factors that may increase the risk of amputatio...
Would you continue Rituximab infusions in a patient with GPA and renal involvement who has been in remission on Avacopan and Rituximab, but had PRES post Rituximab infusion?
PRES (Posterior reversible encephalopathy syndrome) is a potential complication reported with rituximab (RTX) use, not only in rheumatology but also in the oncology literature. It usually resolves, however, there are reports of potential mortality, and of course, morbidity while it is ongoing.If PRE...
Do you routinely isolate and test for TB in a patient incidentally found to have a miliary pattern of nodules on chest CT?
The short answer is yes. CDC recommends applying airborne isolation for any "suspected" case of TB. So if you suspect, you should isolate until you rule out with 3 negative AFB or have an alternative diagnosis. Keep in mind pretest probability and risk factors for that patient with the miliary patte...