Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you check ANCA titers in a patient with a history of PR-3-ANCA glomerulonephritis in remission and a stable creatinine but with recurrent microscopic hematuria?
Not sure there is an easy answer to this. A patient in remission should not get a recurrence of glomerular hematuria unless the disease is active. A new onset glomerular hematuria would certainly make me worried about a relapse, some of which may be subtle, indicating "grumbling disease". The data o...
Would you recommend waiting for a low Vitamin D level to correct to goal prior to giving a scheduled Prolia injection when transitioning a patient from Zolendronic acid to Prolia therapy for worsening osteoporosis?
When ZA is in its early days patients had to have a D level of 15ng/ml. To be on the safe side most of us want a 25 ng/ml level which is easy to obtain.
What is your experience with using anabolic therapy for treatment of osteoporosis in patients with EtOH cirrhosis and is one agent preferred over another (PTH analogue vs Evenity)?
The approach that has been recommended may be reasonable. It is important to recognize that a bone density score consistent with osteoporosis does not necessarily mean that the patient has osteoporosis i.e. loss of mineral and matrix. Osteomalacia, a mineralization defect of the collagen elastin mat...
Are SGLT2 inhibitors contraindicated in patients with osteoporosis and history of vertebral and hip fractures?
In ovariectomized mice, the GLP-1 agonists were found to improve bone density by reducing the inflammation in the bone marrow so there is no contra-indication for a patient with osteoporosis and vertebral fractures to take this class of medications. It is the first weight loss therapy that is not as...
If a patient has potential arrhythmic-sounding syncope and a noninducible type 2 or 3 Brugada ECG pattern, have we excluded Brugada syndrome as the etiology for their syncope?
This is a complex question with a few nuanced components. The first component is qualifying an arrhythmic versus non arrhythmic cause of syncope. I would stress that this is based on generalization as there are no features that will provide absolute certainty for the nature of a single syncopal even...
How do you treat a patient with moderate dementia who experiences a recurrence of depression?
When I get a patient with moderate dementia and depression, I make sure the basic potential reversible medical contributors have been looked into and corrected (i.e., B12/D3 deficiency, OSA, etc). If the patient is on medications that could contribute to depression, I discuss with PCP and family if ...
Is there any benefit in maintaining statin or aspirin therapy in patients >75 years old with stable, multivessel ischemic heart disease in light of challenges encountered with polypharmacy?
This is a great geriatric cardiology question because it acknowledges that guidelines may not apply in an older patient with multiple medical problems and a complex medication regimen. The question further implies that treatment should be individualized and patient-centered. I agree with the questio...
Is there any benefit in maintaining statin or aspirin therapy in patients >75 years old with stable, multivessel ischemic heart disease in light of challenges encountered with polypharmacy?
This is a great geriatric cardiology question because it acknowledges that guidelines may not apply in an older patient with multiple medical problems and a complex medication regimen. The question further implies that treatment should be individualized and patient-centered. I agree with the questio...
How do you approach the management of ADPKD in pregnancy, considering the need to stop tolvaptan therapy?
I generally consider transition to pregnancy with respect to both tolvaptan and ACEi along the same time frame... discuss when initiating counseling about becoming pregnant and discontinue use when patient is about to start actively trying to conceive.Additional counseling may be warranted re: blood...
How will your approach to screening and diagnosis of early dementia change given newly available therapies for early Alzheimer's disease?
As it stands, it is not recommended to screen asymptomatic patients for the proteins seen in Alzheimer’s disease outside of clinical trials (i.e., AHEAD 3-45). However, with the emergence of new treatment options in the clinic, I foresee an influx of patients with cognitive symptoms who need a preci...