Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach therapy for severe osteoporosis after an initial 12 months of romosozumab?
After 12 months of romosozumab, most likely the patient will still need additional therapy. If you can get a bone mineral density, that can guide you into what the best next medication can be. If the patient still has significant osteoporosis or fracture during the treatment with romosozumab, I woul...
What monitoring do you routinely perform on lifelong EDS for epilepsy syndromes?
One of the complications inherent in using AEDs in anybody with epilepsy syndrome or neurotypical people with seizures is bone loss. It is especially important to look at their early loss of bone mass. I check for vitamin D levels even in very young patients. I might even do DEXA scans. I'm very pro...
What therapies have you found most effective in treating teenagers with recurrent CARP?
I have found CARP to be uniformly responsive to minocycline. In my experience, the incidence of recurrence is low and normally responds to minocycline.
Are there instances when you dose sodium zirconium cyclosilicate more than once daily for long term therapy for patients with end stage kidney disease and hyperkalemia?
Not for long-term therapy. I definitely use it more than once daily to lower serum potassium levels acutely, in patients who have clotted their access and are unable to dialyze for 1-2 days until they get decloted, etc. I would imagine that it would be safe to use long-term more than once daily exce...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...
What approaches do you take to prevent worsening kidney function for patients with chronic kidney disease who have an upcoming outpatient CT scan with iodinated contrast?
If CT is really necessary, if not very high risk just encourage moderate oral hydration before and after. May hold diuretics if this can be done safely. If very high risk try to get IV saline for a few hours prior.
Do you always perform salivary gland biopsy to confirm the diagnosis In patients with suspected seronegative Sjogren's syndrome?
I often struggle with the decision of obtaining a biopsy in suspected Sjogren's in a person who is seronegative, when the main issue is dryness, and the main reason is that I wonder if it will make a difference in management. When I was a Rheumatology fellow, I was taught to give Hydroxychloroquine ...
How do you approach managing patients with diabetic kidney disease and proteinuria who develop hypoglycemia after initiation of a SGLT2 inhibitor?
I would first determine if there are other medications the patient is on that reduce the blood glucose. Hypoglycemia with SGLT-2 inhibitors is usually due to something else. Another medication is most likely. Could be very poor dietary intake. Could lower the dose if not on the lowest available dose...
Given recent data from the REPRIEVE trial, how will you adapt your practice with regards to prescribing statins to patients living with HIV?
This randomized controlled trial (Randomized Trial to Prevent Vascular Events) found that, for people living with HIV between the ages of 40 and 75 years who were taking pitavastatin calcium, the risk of major adverse cardiovascular events was lowered by 35% and the risk of cardiovascular death was ...
Given recent data from the REPRIEVE trial, how will you adapt your practice with regards to prescribing statins to patients living with HIV?
This randomized controlled trial (Randomized Trial to Prevent Vascular Events) found that, for people living with HIV between the ages of 40 and 75 years who were taking pitavastatin calcium, the risk of major adverse cardiovascular events was lowered by 35% and the risk of cardiovascular death was ...