Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to use of D-mannose for prevention of recurrent uncomplicated cystitis?
Unfortunately, in light of Hayward et al., PMID 38587819, I think there is a very limited role for the use of D-mannose for the prevention of recurrent uncomplicated cystitis. Our evidence-based options for the prevention of recurrent uncomplicated cystitis in postmenopausal women without catheters ...
What is your approach to determining which patients with ESKD and pruritis should be started on difelikefalin?
Since difelikefalin is a restricted formulary item at my dialysis units, I am required to reserve its use for patients who have failed antihistamines and neuroleptics. If the patient doesn't have traditional Medicare, there may be issues with difelikefalin reimbursement by Medicare Advantage and com...
In patients with Afib on anticoagulation and concurrent intracranial atherosclerotic disease, would you consider adding an anti-platelet to anticoagulation if there are recurrent events that could be related to the ICAD?
This is a difficult clinical situation. If the new stroke was clearly in the vascular territory related to the ICAD, I would consider adding low-dose aspirin to the anticoagulant. I would also consider using the 2.5 mg dose of apixaban as the anticoagulant to reduce the risk of major bleeding associ...
How should we address the questions about the use of hormone replacement therapy in post-menopausal women who have concerns about its relation to breast cancer?
I am presuming that we are referring to woman that does not have breast cancer. Overall, long term estrogen replacement, especially combined with a progestin, is used much less these days since the Women's Health Initiative trials found an increases in coronary heart disease (CHD), breast cancer, pu...
Would you recommend that a patient with stable coronary artery disease and well-controlled RA on a JAK inhibitor continue on their current therapy?
There is no simple answer for this. It is a difficult situation and I would consider a few things in making a decision about what to recommend. These include the course of the patient’s disease, e.g., duration and severity of disease, their current and previous medication history, and the severity o...
Is it true that a ferritin above 200 essentially rules out iron deficiency?
No, I do not think that a ferritin >200 ug/L essentially "rules out" iron deficiency. Ferritin is an acute phase reactant and can be elevated in myriad conditions including kidney disease, autoimmune disorders, etc. The transferrin saturation (measure of serum iron/TIBC) is an important marker of ir...
Does PT/PTT elevation due to severe vitamin K deficiency protect against thrombosis?
Yes, most of us think that vitamin K deficiency increases the risk for bleeding rather than protecting against VTE.
In patients with concurrent, CAD and atrial fibrillation, more than 1 year post-PCI, the most recent AHA/ACC guidelines state that “oral anticoagulation monotherapy is recommended over the continuation of oral anticoagulant therapy and a single antiplatelet therapy.” If this individual undergoes surgery, the anticoagulant will be held. Would you then bridge with aspirin?
This depends on the surgery and for how long anti-coagulation needs to be held. For example, if the patient is undergoing CABG, then the answer is yes, and aspirin seems reasonable. But for some surgeries, all 3 drugs would need to be held (ophtho or some neurosurgical/spinal procedures for example)...
Should lipid lowering therapy be started in patients with isolated elevation in lipoprotein (a) and minimal cardiovascular risk?
At the current time the answer would be "no" for someone with minimal CVD risk. There are not any currently available therapies for effectively lowering Lp(a) nor randomized trials demonstrating clinical efficacy, though this could change in the near future.
Should patients with mild subclinical hypothyroidism (TSH < 10 mIU/L) be treated with thyroid hormone replacement to improve their lipid profile?
There is a well-known association between untreated primary hypothyroidism and hypercholesterolemia with subsequent improvement of lipid profile following thyroxine replacement. However, the link between hyperlipidemia and sub-clinical hypothyroidism is less well understood. The all-important questi...