Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
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...