Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider a biologic or JAK inhibitor to manage active PsA in a patient on chronic antibiotic therapy if they had previously failed all conventional DMARDs (including apremilast)?
IL-23i such as guselkumab have not really shown a significantly higher incidence of infections or malignancies, so I would favor these over other biologics. Ustekinumab (IL-12,23i) also showed lower rates of infection compared with other biologics. However, something to consider is whether they have...
What criteria do you use, if any, to recommend statin therapy for patients with polycystic kidney disease?
If the patient has an indication for a statin for cardiovascular risk factors, I will of course recommend statin as per AHA guidelines. For low-risk individuals (e.g. young PKD patients) with borderline lipids, we will discuss the theoretical pleiotropic effects of statins with respect to ADPKD. Dep...
Would one year of steroids for JRA during teen years (with subsequently well-controlled autoimmune disease) be sufficient to explain a vertebral T score of -4.4 of a woman in her early 50s without any other risk factors?
This is a tough question. It is clear that teenage years with GCs would impact peak bone mass, however not to this extent. A T score of -4.4 is the result of a low peak bone mass, genetics, and factors that affect the bone mass between ages 25 to 30. I would put forth part of the low BMD is from GC ...
Do you recommend obtaining 24 hour urine ammonium levels in patients with recurrent uric acid nephrolithiasis?
An astute question! As you imply, uric acid stones have very little to do with uric acid! Otherwise, we would see more sodium urate, potassium urate, and ammonium urate stones, which are very rare. Uric acid (hydrogen urate) stones are highly dependent on a lower-than-normal urine pH. The two main r...
Are there preferred home exercise programs for patients without access to pulmonary rehabilitation?
There is Pulmonary Rehab toolkit on the pulmonary fibrosis foundation website. I will generally show it to patients and have them bookmark it on their phones.
For patients on PrEP, is there a role for HIV RNA PCR screening in addition to 4th generation antigen/antibody testing?
Absolutely (if possible)! Particularly in the setting of injectable PrEP, the medication can suppress viral replication even if HIV is not prevented. Unusual results can be observed, with either positive viral loads or positive antigen/antibody tests. PCR screening would also give the shortest windo...
How would you approach a postmenopausal patient on Letrozole who developed cataracts within the first six months of treatment?
While tamoxifen has been associated with ocular toxicity like cataracts, there has not been any conclusive or convincing connection between aromatase inhibitors and cataracts. Since the alternative to aromatase inhibitors is tamoxifen which we know may be associated with cataracts, and given the la...
Would atypical fractures of the hip in a parent (treated with bisphosphonate) be considered when calculating the FRAX score for a patient with osteopenia?
There is no data regarding this question so my response is only my opinion. I would not include a parental hip fracture secondary to bisphosphonate use in the FRAX prediction model since such fractures are not (by definition), typical hip fractures (femoral neck or intertrochanteric regions). Howeve...
Would you order a DEXA scan for a cervical cancer patient with osteoporosis?
This is a great question and one that we should all be contemplating. I do order Dexa scans on all of my post-menopausal patients if they have not had a current baseline. Many of them have lifestyle issues that could also have decreased bone density such as low weight, tobacco and alcohol use, etc. ...
Do you avoid losartan in patients with hypertension and uric acid nephrolithiasis due to the drugs uricosuric effects?
This is an important question. I continue to use losartan or other uricosuric drugs in uric acid stone formers. Control/prevention of uric acid stone formation is primarily related to raising urine pH to 6.5 (at least above 6), since uric acid solubility is so strongly dependent on pH. Any minor inc...