Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How long does it take the hypothalamic-pituitary-gonadal axis to recover from secondary amenorrhea in the setting early onset and chronic use of oral combined contraceptive pills?
About 6 months after cessation of OCs.
Do you recommend the use of automated insulin delivery systems (such as Control IQ with Tandem insulin pumps) for managing gestational diabetes?
Currently, none of the current FDA-approved AID systems have algorithms set to achieve pregnancy-specific glucose goals. So using the manual mode with overnight target 90 along with appropriate bolus settings to keep PPG at goal is the most efficient.
Do you recommend using vitamin D analogs for patients with CKD and a high PTH but a normal 25-hydroxy vitamin D level?
The answer is that it depends on how high the PTH level is. KDIGO guidelines originally recommended targeting PTH between 65 and 130 for patients with non-dialysis CKD by using nutritional vitamin D if the 25-OH vitamin D level is low and using active vitamin D if the 25-OH vitamin D level is normal...
Below what ejection fraction would you avoid referral for AV access creation in a patient with advanced CKD and heart failure with reduced ejection fraction?
I would not refer a patient with advanced CKD and heart failure with an ejection fraction less than 30-35% for a hemodialysis vascular access for fear of worsening the heart failure. In addition, in my experience, if an arteriovenous fistula is placed in such a patient, it usually does not mature du...
Do you recommend genetic testing for patients incidentally found to have nephrocalcinosis on imaging?
In general, yes, but it’s usually not my first step if my family history is negative for nephrocalcinosis. These patients typically have unusually alkaline urine and often pass calcium phosphate stones. I rule out primary hyperparathyroidism and incomplete distal RTA. I look for medications that can...
How do you counsel patients with elevated factor VIII levels for their thrombosis risk?
I don't check the factor VIII level as part of a thrombosis workup because the result rarely if ever affects my management of these patients. I would explain to the patient that factor VIII levels are a function of several variables, including age, vascular health (and hence blood pressure, smoking,...
How do you approach medication management in patients with RA when transitioning from csDMARD triple therapy to anti-TNF?
There is not a one-size-fits-all approach to this question. Drug transitions can be influenced by several factors including individual side effects of medications, patient preference for other reasons, disease co-morbidities, ability to use prednisone as bridge therapy, etc. In general, hydroxychlor...
Would you consider lifelong versus short-term (i.e. several months) course of anticoagulation for patients with elevated CHADSVASc score presenting with newly diagnosed paroxysmal atrial fibrillation triggered in the setting of acute illness (i.e. tachyarrhythmias with COVID-19 or bacterial pneumonia)?
AF during an acute illness could result from the stress of an infection, however, these patients do seem to be at higher risk of recurrence. It might also simply represent the first time that AF has been recognized in a patient who is at risk for atrial arrhythmias. Anticoagulation is indicated in t...
Is reduction in proteinuria with SGLT2i dose dependent?
My understanding of dosing with empagliflozin, in particular, is that it is not dose-dependent, thus a dose of 10 mg versus 25 mg will lead to a similar reduction in proteinuria. This is based on data from the EMPA REG OUTCOME trial published in NEJM in 2016. The composite outcome of incident or wor...
Should thyroxine hormone be started in women having fertility concerns with high-normal TSH and negative TPO antibody?
This landmark NEJM trial showed no benefit in women with TPO antibodies and a TSH > 2.5 of starting levothyroxine. However, most IVF centers start low-dose levothyroxine since subclinical hypothyroidism is associated with an increased risk of miscarriages especially if TSH > 5 or TSH > 2.5 with posi...