Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In a patient with sickle cell disease on hydroxyurea who is planning to have a family, for how long should they be off the drug before trying to conceive?
There is some consensus that pregnant women should not take hydroxyurea and should stop taking this when found to be pregnant. (Smith-Whitley, PMID 25472967) As far as I know, there is no data on how long hydroxyurea should be discontinued in either men or women before attempting pregnancy. In fact,...
Is there a role for vascular intervention in patients with renal artery stenosis found during work up of resistant hypertension?
The ASTRAL, STAR, and CORAL trials all attempt to this question in different patient populations. A portion of CORAL participants met the diagnostic criteria for resistant hypertension. What I have taken away from the data is that renal artery intervention can be helpful in fibromuscular dysplasia i...
What is the next best anti-hypertensive medication to start after mineralocorticoid receptor antagonists in patients with primary aldosteronism?
I have had a good experience with calcium channel blockers and combined alpha/beta-blockers such as carvedilol in patients with PA. They are my first and second choices after MRA. If tolerated, pushing the MRA dose to get a PRA> 1 ng/ml/hr is important. I check for proteinuria, and if present, I add...
How do you counsel HIV patients with an undetectable viral load on breastfeeding?
People who are virally suppressed on ART are at very low risk of transmission to infants through breastfeeding, less than 1%-- however, the rate is not 0, and any infant with HIV is heartbreaking. The risks are particularly high in infants who are transitioning to solid foods (potentially related to...
Do you take any special approaches with patients with recurrent nephrolithiasis who first developed stones prior to adulthood but have negative kidney stone disorder genetic test findings?
No. My pediatric kidney stone consultants tell me kidney stones in childhood are relatively common. If genetic testing is negative (or even if it is positive), I treat them starting with general dietary modification, tailored to their urinary supersaturation data and stone composition, if known. Ste...
Do you recommend continuing SGLT2 inhibitors in patients with diabetic kidney disease and congestive heart failure who have been taking the medication for several years and later develop end stage kidney disease?
The very premise on which SGLT2i is supposed to work does not exist, if the patient does not have meaningful GFR; in fact most would not use/start SGLT2i once eGFR is <20-25 range. Studies have excluded patients with advanced CKD and any benefit with low GFR seems very doubtful. Zinman et al., PMID...
Do you recommend using doses of ACEi or ARBs that is above the usual dosing with the goal of reducing a patient's proteinuria further?
No, doses above the therapeutic maximum typically result in more side effects without additional benefit. For example, the VA NEPHRON D study showed increased rates of hyperkalemia and AKI with dual RAAS blockade. We now have more medication options to reduce proteinuria including SGLT2-INHs and fin...
How do you treat persistent headache after RCVS?
To my knowledge, there are no published studies to guide treatment decisions for headaches related to RCVS. Therefore, I would base treatment on the headache phenotype. In my experience, the most common phenotype is chronic migraine. Literature suggests that a prior migraine diagnosis is a risk fact...
How would you manage a patient with distal rectal adenocarcinoma involving the anal canal and a single non-bulky inguinal nodal metastasis?
Patients with low rectal cancer and inguinal involvement at presentation should obviously be treated with curative intent because inguinal lymph nodes are first echelon drainage from the low rectum and anal canal. Standard dose neoadjuvant chemoradiation and limited surgical excision of the involved...
Should weight loss medications be used in women who are gaining excessive weight during pregnancy?
No weight loss medications are currently known to be safe during pregnancy and should be avoided even in cases of excessive weight gain. Exercise, diet, and behavioral modifications are the mainstay of treatment for weight gain/obesity in pregnancy. Bupropion/naltrexone (Contrave) as well as GLP-1RA...