Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When would be the appropriate time to refer an asymptomatic young adult with unicuspid AV s/p valvuloplasty during adolescence for AVR following exercise stress TTE findings demonstrating increase in aortic valve mean gradient from 40mmHg to 70mmHg (achieving 15 METS)?
Great question and the correct answer is: ALWAYS feel free to refer a complex case like this to advanced pedi/ACHD centers. In terms of whether the patient will need or get a prompt AVR… it DEPENDS!First, we need to prove severe aortic stenosis (mean of 70 mmHg seems legit). As is often the case in ...
Do you ever consider using a higher dose of upadacitinib (30 mg daily) for rheumatoid arthritis in patients who fail to respond/partially respond to established dosing of 15 mg daily?
The FDA-approved dose of upadacitinib (UPA) for the treatment of RA is 15 mg per day. In other diseases, such as psoriatic arthritis (PsA), atopic dermatitis (AD) and ulcerative colitis (UC), higher doses (30mg and 45 mg per day) have been studied and shown to be efficacious and relatively safe when...
Would you consider using a JAK inhibitor in combination with an IL 23 inhibitor in cases of severe psoriasis, psoriatic arthritis, or axial spondyloarthritis that is refractory to multiple biologic DMARDs?
Differential skin and joint responses in psoriasis, PsA and Axial SpA are not uncommon. Many PsA/PsO experts and scientists have postulated the potential benefit of using combination biologic (perhaps in serial fashion or lower doses of each) to treat these cases where there are suboptimal responses...
Where do you place romosozumab in your treatment sequence for osteoporosis management?
I agree. It is very effective as first-line therapy in patients at high risk for fracture. It can also be useful post bisphosphonate therapy. I have used it successfully multiple times to transition patients from long-term Prolia therapy without loss of bone mass.
When do you restart ACEi/ARB medications for patients whom these medications were previously discontinued due to acute kidney injury?
I generally wait until the patient’s kidney function has stablilized at a new baseline, the patient’s acute illness that led to AKI has resolved and the serum potassium is acceptable.
Do you use alkali therapy in those with stable chronic kidney disease and a normal serum bicarbonate level who have a low urine pH?
Generally, no. There is no reason to increase the pill burden with bicarbonate therapy in a patient with normal blood chemistry. I would only treat urine pH in a stone-forming patient with uric acid stones.
How much decrease in eGFR do you tolerate before discontinuing a SGLT2i started in patients with diabetic kidney disease?
SGLT2i are known to have an acute, reversible dip in eGFR in the first 2-4 weeks after initiation. This effect on glomerular hemodynamics (more pronounced in diabetics) usually decreases eGFR by less than 30% and has been associated with better long-term cardio-renal benefits in some studies. A dip ...
How much decrease in eGFR do you tolerate before discontinuing finerenone started in patients with diabetic kidney disease?
I use the same approach investigators did in the Fidelio DKD study: patient on max dose of ACEi/ARB. Add finerenone--> check GFR in 4 weeks. If more than 30% drop hold any NS-MRA up titration and recheck GFR in 1 week. If stable, continue same drug regimen, if GFR further decreases, hold finerenone,...
Do you obtain periodic kidney ultrasounds in patients with stable chronic kidney disease to evaluate for changes in kidney size that might reflect progression of kidney disease not detected with serum studies?
I would not check an ultrasound for this reason alone. Renal ultrasounds are incredibly useful in the initial diagnostic work-up for CKD and/or if there is a sudden change in blood pressure or kidney function. But, I would never change my management of CKD based on subclinical changes in the renal u...
Do you treat low 25-OH vitamin D levels in those with end stage kidney disease?
Low 25-OH vitamin D levels in those with end-stage kidney disease should absolutely be treated. The assumption that calcitriol administration satisfies all the vitamin D needs of the body is incorrect. While it is true regarding the endocrine effects of calcitriol (calcium and phosphate homeostasis)...