Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you adjust immunosuppression in lung transplant recipients diagnosed with COVID-19?
Adjustment of immunosuppression in the setting of infection is center dependent after transplant. At our center, we typically only adjust if needed, other centers will empirically stop Mycophenolate. We typically monitor the white blood count and Prograf levels daily. If the patient we adjust the Pr...
Do you feel comfortable using azathioprine for dermatomyositis in patients with cirrhosis?
Azathioprine can cause liver damage, albeit this is a rare complication and usually asymptomatic. Therefore, I would probably avoid it in cases of liver cirrhosis and try other medications, like mycophenolate, IVIG, tofactinib. In either case, I would consult at the same time with the patient's hepa...
At what point do you recommend muscle biopsy in the workup for myositis?
Muscle biopsy is generally recommended and useful in most cases of suspected inflammatory/immune myopathy; accurate pathologic diagnosis is imperative for prognostication, identification of comorbid conditions (e.g., cancer, interstitial lung disease, arthritis, etc.), and treatment decisions. Histo...
To what extent does the degree of thrombocytopenia correlate with the severity of cirrhosis?
The degree of thrombocytopenia in cirrhosis is dependent on multiple factors. Decreased production of thrombopoietin by the liver. This can usually be overcome by the administration of a TPO-receptor agonist IF an increase in count is needed for a procedure and there is at least a week to prepare. ...
How do you approach relapsing ANCA-associated vasculitis in a patient who has already undergone kidney transplant?
In a very individualized way (What has the patient been treated with before? What is the current transplant immunosuppression? etc.) and in conjunction with a transplant nephrologist. One could imagine re-induction with rituximab would work in many cases but specifics about each individual case will...
How long after starting anticoagulation would you remove an IVC filter in a patient with a DVT presenting with stroke and PFO which is now closed?
This can be a complex scenario. The first question to ponder: if the patient could receive anticoagulation (a/c), why was the filter placed? Let us assume that there was a short period of time from the initial presentation of stroke, during which anticoagulation was contraindicated and there was a l...
What criteria do you use to consider pleurodesis vs indwelling tunneled catheters in patients with malignant pleural effusion?
There are typically three approaches that are used for the management of recurrent malignant pleural effusions. The first approach is to perform repeated thoracentesis. This may be acceptable if there is a significant duration of time between recurrent symptomatic pleural effusions. The other two ap...
How do you counsel patients regarding prognosis following a diagnosis of IPF?
Are you using NAC in lieu of hypertonic saline amidst the current shortage of hypertonic saline in patients with either CF or non-CF bronchiectasis?
The Mogayzel and colleagues guidelines for maintenance of lung health do not recommend for or against NAC in the treatment of CF Lung disease. In contrast, they do recommend the chronic use of HTS. Mogayzel Jr et al., PMID 23540878In CF and Non-CF bronchiectasis, my first choice is inhaled hypertoni...
With the approval of oral JAK inhibitors such as Upadacitinib for atopic dermatitis, how are you considering its safety profile in comparison to traditional immunosuppressants such as prednisone, methotrexate, azathioprine, and mycophenolate?
In every treatment situation, we need to help the patient understand the potential benefits and potential risks of a medication. In my opinion, Upadacitinib is in a completely different category than traditional immunosuppressants such as prednisone, methotrexate, azathioprine, and mycophenolate, si...