Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What would be your next step in treating a patient with osteoporosis who developed AFF on denosumab and who then completed one year of romosozumab?
There is no evidence-based answer for this question. First of all, the development of AFF while on osteoporosis doses of denosumab is very rare. It usually occurs in people who have previously been on bisphosphonates. I would most appropriately assess fracture risk after the romo and then determine ...
Do you recommend switching to a non-dihydropyridine calcium channel blocker with the goal of decreasing proteinuria in a proteinuric, hypertensive CKD patient already on a dihydropyridine calcium channel blocker?
Blood pressure control has a more powerful effect on reducing proteinuria than the type of calcium channel blocker. It is often difficult to achieve the goal of BP < 130/80 mm Hg while on a non-dihydropyridine CCB. I chose to focus on other anti-proteinuric agents like SGLT2-INH, MRA, and ACEi/ARB, ...
What is your blood pressure goal for a pregnant patient on hemodialysis?
This is a great question with very little evidence behind it. In pregnant patients, just as in non-pregnant patients, the target for BP should be based on their home readings between treatments, rather than readings at the beginning or end of dialysis. I target < 140/90 mm Hg, consistent with the ap...
How would you approach a patient who has well controlled SLE on HCQ but develops cotton wool spots on routine ophthalmologic screening?
Cotton-wool spots are estimated to occur in 10-15% of SLE patients. Etiology is either thrombotic pathology from associated APS, vasculitis or atherosclerosis. Treatment is targeted to the underlying etiology: eg anti-coagulation for APS, immunosuppression for vasculitis or minimization of atheroscl...
Do you recommend performing cognitive testing in the clinic to determine the blood pressure target in patients 80 years or older?
SPRINT-MIND helps to answer this question. The total number of individuals developing dementia (the primary outcome in SPRINT-MIND) was fewer then expected after a median intervention period of only 3.3 years. This made SPRINT-MIND underpowered to detect the effects of intensive BP reduction on deve...
How do you counsel patients regarding alcohol intake when prescribing DMARDs other than methotrexate?
I always inquire about alcohol intake before starting any drug with a known issue of hepatotoxicoty, using the “Law of Two” I learned as an intern: alcohol abusers under-report their intake by a factor of two. Assuming there is no such red flag to avoid the drug, I tell my patients that alcohol is n...
What is your approach to elevated urine uric acid levels in a recurrent calcium based stone former?
There was good evidence from controlled trials supporting the use of allopurinol in hyperuricosuric calcium stone formers. That said, the trials are now pretty old and I would tend to treat other risks first (unless there was another reason to lower the uric acid like gout). In general, a lower anim...
Do you recommend stopping Vitamin D supplementation in a patient with hypercalcemia and a low 25(OH)D level?
Even though nutritional vitamin D does not normally cause hypercalcemia except in very high doses, I'm not so confident that it is not a contributing factor to the problem in dialysis patients. The reason is mainly a lack of data in this population which has some unique issues related to PTH levels,...
How would you manage tubulointerstitial nephritis and renal tubular acidosis (RTA) in a patient with Sjogren's who is pregnant?
The most common form or renal disease in Sjogren's (SjD) is tubulointerstitial nephritis. This may result in tubular dysfunction leading to renal tubular acidosis (RTA), most commonly type I RTA leading to hypokalemia and a non-anion gap hyperchloremic acidosis. Over time, nephrocalcinosis can occur...
Do you recommend starting aspirin for a patient with ESKD secondary to lupus nephritis with detected antiphospholipid antibodies on pretransplant workup but no history of a thrombotic event?
I offer it to my SLE patients (especially those with lupus nephritis) and discuss the pros and cons of using ASA plus HCQ for CV event prevention. I do this with all of my SLE patients.While our SLE patients as a whole are at high risk for CV events (top 1-2 causes), our patients with lupus nephriti...