Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Are there instances when you prefer serum creatinine over cystatin C when estimating GFR in a patient with CKD?
Overall serum cystatin C correlates better with measured GFR than does serum creatinine. The main block to more widespread use of cystatin C is its cost. I personally have not had an experience where the serum creatinine has been a better measure of GFR as opposed to serum cystatin C but there is da...
How do you approach monitoring when using combination JAK inhibitors and methotrexate in RA?
It is important to return to the package insert and/or the original clinical trials for these medications when considering options for care and use. Tofacitinib, for example, when tested for the management of rheumatoid arthritis, was in phase 2 and 3 studies in combination with DMARDs, including me...
What is your approach to counseling and management of patients with severe symptomatic OSA whose PAP devices have been recalled?
Continue to use it with or without a microbiological filter. The latter is not necessarily recommended by Respironics but is an option nevertheless.
What is your approach to progressive calvarial hyperostosis found in an elderly adult not caused by Pagets, acromegaly or hypercalcemia?
Does your patient have meningioma? Is the osteosclerosis generalized or localized? Localized osteosclerosis can arise from tumors (either benign or malignant) that secrete osteogenic proteins. I have had such a patient, with the unresectable meningioma secreting endothelin. Endothelin is also secret...
What is your management approach for patients with Adult Onset Still's who are planning pregnancy?
Adult Onset Still's Disease is an uncommon disorder. There are a paucity of studies of this disease during pregnancy. Nonetheless, as rheumatologists, we are occasionally asked to manage these patients during pregnancy. The treatment of Adult Onset Still's Disease includes NSAIDs, glucocorticoids, m...
Would you start any treatment for radiation pneumonitis if there is a large area of consolidation in the irradiated lung field but the patient is asymptomatic?
If the timeline matches then for radio graphic only pneumonitis, I would favor observation with a repeat scan in a few months.
Which types of patients do you treat with prolonged antibiotics before obtaining a CT sinus?
If the patient has had symptoms of chronic rhinosinusitis for more than 7 days I would give a 10-day course of Levoquin. The symptoms I look for include purulent post-nasal drainage, nasal congestion, and lethargy. If the patient does not respond in 203 days, I would obtain a sinus CT.
Is there a role for nintedanib in the management of patients with radiation-induced pulmonary fibrosis?
There is no phase III evidence I am aware of on the benefits of nintedanib in the prevention of radiation-induced pulmonary fibrosis so it is not a drug I use. There are a few case reports and some pre-clinical studies suggesting an effect. There is a small (34 patients) randomized phase II study th...
At what point in GCA management do you typically introduce tocilizumab?
I typically introduce tocilizumab as first line therapy in combination with prednisone in patients who do not have a contraindication. The GIACTA trial demonstrated the superiority of TCZ+prednisone x 6 mos over prednisone alone x 6 or 12 months with numerically fewer serious adverse events. Given t...
When and how do you taper off cabergoline therapy for treatment of microprolactinoma?
If patient does not desire fertility and microprolactinoma is stable or smaller, cabergoline can be tapered off.