Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider using finerenone for proteinuric CKD associated with type 1 diabetes mellitus?
Yes, although T1DM is off-label for finerenone and there may be issues regarding its approval by prescription drug plans. I would start with an ACEi/ARB for proteinuria in a T1DM patient, then add spironolactone. If the patient develops breast problems on spironolactone, I would switch to eplerenone...
How would you approach a patient with axial spondyloarthritis who develops new-onset proteinuria?
I would approach the workup for proteinuria based on the differential diagnosis with leading etiologies including, acute illness, diabetes, nephrotic syndrome (minimal change disease, FSGS, membranous neuropathy), drug-induced proteinuria, vasculitis, and of course IgA neuropathy. Standard studies i...
Do you use vitamin B6 to help with Keppra irritability?
I am an adult epileptologist and do not routinely prescribe pyridoxine for neuropsychiatric adverse effects of levetiracetam. I do see this done a lot more in the pediatric population, where there is more data than is available in the adult population (though still not of very high quality). Anecdot...
How would you manage a patient pre-operatively with a prolonged PTT that does not correct on mixing, with lupus anticoagulant testing that is abnormal by LA-PTT only?
Not all reagents/assays exhibit the same sensitivity (aka responsiveness) to lupus anticoagulants (LAC). In this case, there is evidence of LAC based on one assay, LA APTT. Often we see prolongation/inhibition in other assays e.g. APTT, but the phospholipid neutralization (PNP) step is not always di...
Are there instances when you would pursue a kidney biopsy in a pregnant patient instead of waiting to perform the procedure post-delivery?
Prior to 20 weeks, consideration of a biopsy shouldn't be different than how we would think about biopsy in a non-pregnant individual. The pregnancy is still pre-viable, and so knowing a diagnosis and treating the disease with the goal of improving the kidney function, and thus the pregnancy, makes ...
How do you decide when to refer patients with obstructive hypertrophic cardiomyopathy for alcohol septal ablation versus septal myectomy?
If a patient with obstructive HCM remains severely symptomatic despite being on maximal standard-of-care medical therapy, (beta blockers, non-dihydropyridine calcium channel blockers, addition of disopyramide for combination therapy, or a cardiac myosin inhibitor if appropriate), septal reduction th...
What are your outpatient surveillance strategies (biomarkers, imaging, symptoms) to monitor response to treatment for ATTR amyloidosis with cardiac involvement?
I continue it indefinitely. Limited survival data shows a beneficial effect for at least 5 years with survival on the drug of 55% compared to 37% on placebo.Elliot et al., PMID 34923848However, if patients deteriorate dramatically on therapy and are class IV NYHA, I discuss with patients and family ...
What would be your approach to a SLE patient who is triple APS positive, has no prior VTE/obstetric events, is stable on HCQ and low dose aspirin, and wants to become pregnant?
As long as lupus is well controlled, I would not recommend making any changes. I would also reassure this patient that having prior successful pregnancies (based on the information provided in the question stating that there were no prior obstetric complications) is a good sign. I would not prescrib...
What is the recommended treatment regimen for Mycoplasma genitalium in a pregnant woman?
Great question for which there isn't a great answer. I would consider why the patient was tested. Asymptomatic pregnant people should not be screened for M. Genitalium. For asymptomatic people who are tested for whatever reason for M. Genitalium, it should be a discussion and a shared decision betwe...
Is it ever appropriate to restart bipshosphonates following a drug holiday in a patient with a prior atypical hip fracture?
I agree with Dr. @Dr. First Last. I am not likely to ever prescribe a bisphosphonate after someone has had an AFF (or ONJ) attributed to the bisphosphonate. Anabolics make sense if you can get them paid for. Raloxifene is fine but there is no evidence for non-vertebral fracture risk reduction. Venou...