Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
Considering only cerebrovascular indications, are there circumstances in which you would use aspirin along with a DOAC in patients with atrial fibrillation and stroke?
I will use aspirin 81 mg and a DOAC together in patients who "fail" (I hate that term) the DOAC. The combination was used in patients in the original DOAC trials, so it is not unreasonable. Not my first choice, but can be done. It is worth noting that the evidence does not support doing this upfront...
What circumstances would drive you to consider using an oral IL-23 inhibitor over parenteral options for the management of psoriasis and/or psoriatic arthritis?
Psoriatic arthritis is a heterogeneous disease and the choice of therapy is driven by many factors.The most important factors in the decision tree are whether the patient has 1) axial disease and/or 2) severe psoriasis.Additional Considerations include: prior therapies, extramusculoskeletal manifest...
Would you consider utilizing transdermal estrogen for HRT to treat severe hot flashes in a patient with SLE and a history of thrombosis x2 and positive lupus anticoagulant, but negative aCL/B2GP1 abs?
Given the prothrombotic effects of estrogen, they are generally avoided in patients with prior thrombosis and hypercoagulable states. Therefore, in a patient with SLE, secondary anti-phospholipid syndrome, as a single positive aPL with a positive lupus anticoagulant, and prior thrombotic event, the ...
When would you consider using amiloride over spironolactone for treatment-resistant hypertension (not reaching goal BP on 3 agents, including a diuretic)?
In male patients, because of the high incidence of gynecomastia...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
What is your approach to treatment of macrolide-sensitive localized bone/joint MAC disease?
Agree with the above answers. Obviously, no strong clinical studies on duration and outcomes. At NJH, we typically recommend: Aggressive debridement/resection, Treat with appropriate antimicrobial therapy (in macrolide-S MAC, then AZM/EMB/Rifamycin +/- IV AMK) for a minimum of 6 months total, but a...
Do you favor aspirin or P2Y12 inhibitor monotherapy following completion of 12 months of DAPT post-PCI in patients with elevated bleeding risk?
You could tailor based on bleeding risk. If prior upper GI bleed or symptoms - p2y12. If lower GI bleeds - aspirin. The field is moving towards p2y12 monotherapy. Also as mentioned should do genetic testing if thinking long-term clopidogrel monotherapy.
Do you give chronic antibiotic prophylaxis for recurrent UTIs, including Pseudomonas aeruginosa, in a patient with retained ureteral stents?
If the "recurrent UTIs" are symptomatic (fever is what I would be mostly concerned about), then the stents should be changed as feasible, (I assume this has been done) and the UTIs treated as appropriate. If the UTIs continue after the change, I would just try to treat the symptomatic events as best...
What is your preferred workup for patients who present with concern for autonomic neuropathy?
When patients report one or more symptoms suggestive of autonomic dysfunction, objective confirmation of impaired autonomic function is required. This may include the standard battery of autonomic tests included in the CASS score (tilt table testing, response of HR and BP to Valsalva maneuver, and ...