Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is a reasonable amount of ventricular arrhythmia burden on outpatient remote monitoring that would prompt consideration for VT ablation in patients with normal LV function and mild symptoms?
The concern in this circumstance is the risk of the patient developing a PVC-meditated cardiomyopathy. It is clear that a subset of patients with a high burden of PVCs can be at risk for the development of left ventricular dysfunction. We also have data to show that reduction in the PVC burden for t...
Would you wait a period of time before collecting a 24 hour urine stone risk study in a patient with nephrolithiasis who recently underwent a urologic stone removal procedure?
I generally recommend waiting until the patient is back to steady state, stents are out, pain controlled, and they are back to their usual diet. This time period after urologic procedure varies depending on what the procedure is and if any post-procedure complications and their management.
How do you approach pre-conception counseling in males who are on medications for which there is limited or no data such as Jak inhibitors, apremilast, or belimumab?
I am transparent about the lack of data, but discuss the differences in mechanism of action between cyclophosphamide and thalidomide (the only medications we recommend against conception with a partner) and JAKi, Apremilast, and Benlysta. Prior data has demonstrated a clinically insignificant amount...
Do you treat hypercalciuria in post menopausal osteoporosis with normal serum calcium and PTH?
I ABSOLUTELY recommend treating! This is the sine qua non of secondary osteoporosis with the osteoporosis being a direct consequence of the underlying hypercalciuria. Thiazides are great in this setting. I use chlorthalidone in preference to HCTZ because it has a longer half-life and can be used onc...
What is the best treatment of isolated elevated DHEA-S in a woman with clinical androgen excess (without PCOS, neoplasm, etc)?
It is important to rule out hyperprolactinemia as one of the causes of elevated DHEAS levels. We diagnosed a patient with macroprolactinoma who was referred to us for DHEAS elevation. In my experience, most such patients have either an atypical PCOS or some enzymatic abnormality in their adrenal ste...
Are there special recommendations for the use of hydroxychloroquine and methotrexate together?
In my view, there are no considerations to make when combining these therapies. I’m not sure what the person asking the question was concerned about.
At what point do you consider a patient to have relapsing PMR?
Relapses in PMR are quite common. It is not unusual for patients to do well initially and as steroids are tapered, they start to describe a recurrence of symptoms. My concern is when these relapses occur early. For example, if they are noted as a patient tapers down from 10 mg towards 5 mg/day and r...
What baseline and ongoing testing do you recommend for patients with PMR who are going to be on a prolonged steroid taper?
My answer below is specific to patients with a definite diagnosis of PMR and does not necessarily cover diagnostic testing such as evaluation for possible mimics, which is certainly important and should include infections and malignancy in main differential, or other rheumatic diseases (RA, GCA). Va...
How do you manage vitamin D dosing in patients with nephrolithiasis and hypercalciuria who require supplemental vitamin D for treating other medical conditions?
This is a common treatment for osteopenia/osteoporosis. For calcium stone formers, I watch for hypercalcemia and/or hypercalciuria. If present, I reduce the dose of calcium and/or vitamin-D until their urinary parameters normalize. Otherwise, I think they can take these medications safely in standar...
How do you approach an obese patient on long-term methotrexate with normal liver tests in terms of workup for underlying fatty liver?
Screen with ultrasound.