Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What infections should we rule out in patients who develop diarrhea on immunotherapy?
Immunotherapy is known to be associated with immune-mediated diarrhea and colitis (IMDC). However, it remains unclear whether cancer patients undergoing immunotherapy are at a heightened risk for Clostridioides difficile colitis infection (CDI). A retrospective study focusing on patients treated wit...
When do you consider stenting in patients with recurrent stroke with ICAD?
I agree with the answers mentioned above. Additionally, I ensure that the patient has made diligent efforts to address modifiable risk factors, with smoking cessation being of utmost importance, along with medication compliance. The specific area of stent placement and the type of stent used may var...
What are your recommendations for the long-term management of patients who have experienced Takotsubo cardiomyopathy, particularly regarding ongoing medication management and follow-up imaging?
The management of Takotsubo cardiomyopathy (TTC) focuses on both the acute phase and long-term care. While specific guidelines for TTC are still evolving, a tailored approach based on individual patient profiles and clinical circumstances is recommended. In regards to the long-term medication strate...
How do you counsel patients who wish to travel to high altitudes with myasthenia gravis?
It can be a challenge as high altitude can unleash fatigue, shortness of breath, increased weakness, etc. In a myasthenic patient, it is important to recognize this as some of the symptoms may resemble myasthenic exacerbation acutely. Counseling patients on optimal control of generalized myasthenia ...
How would you manage active psoriasis and psoriatic arthritis in patient on Rituximab and prednisone for MPO positive vasculitis?
The answer is it depends on several factors, the most important being how severe the psoriasis is and if the patient has axial involvement. Since the patient has failed or not responded to methotrexate or apremilast, adding these would not be an option here.While we do not have much data on combinat...
What is your approach to treatment in a patient with radiographic UIP but pathologic evidence of both fibrotic NSIP and UIP?
Depends on the underlying etiology and progression. I will most likely use antifibrotics, particularly for IPF or progressive fibrosis, but include immune suppression for autoimmune-related ILD.
Should methotrexate be categorically avoided in RA patients with COPD or RA-ILD?
Thanks for raising a very important question. It is something that every practicing Rheumatologist comes across several times during their career.The traditional teaching has always been to avoid using Methotrexate in patients with underlying pulmonary conditions due to the associated risk of Hypers...
Should MTX be avoided in RA patients with asymptomatic lung nodules?
It is well established that in some RA patients, methotrexate does cause accelerated nodulosis predominantly in the hands which improves after stopping the medication. That does not mean having pulmonary nodules is a contraindication to use methotrexate. I recommend doing frequent chest x-rays for m...
Should methotrexate be stopped prior to radiation therapy if a patient has rheumatoid arthritis?
I have not stopped as dose of MTX for RA is low (7.5 mg) and there is data of CMF with RT for breast cancer with higher dose of MTX showing no significant increase in morbidity.
Do you avoid triptans in patients on SSRI's due to the potential risk of serotonin syndrome?
I feel very comfortable using triptans with SSRIs/SNRIs. In 2010, the American Headache Society released a position statement on this very issue:Evans et al., PMID 20618823Their position is that the available evidence does NOT support the claim that triptans should not be used with SSRIs or SNRIs.A ...