Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you avoid empagliflozin in patients with history of amputation?
To be clear, you can prescribe any SGLT2i to a patient with an amputation or at high risk for an amputation due to prior foot ulcers, insensate foot, peripheral vascular disease. The "warning" (not contraindication) in the canagliflozin PI is "Consider factors that may increase the risk of amputatio...
Would you continue Rituximab infusions in a patient with GPA and renal involvement who has been in remission on Avacopan and Rituximab, but had PRES post Rituximab infusion?
PRES (Posterior reversible encephalopathy syndrome) is a potential complication reported with rituximab (RTX) use, not only in rheumatology but also in the oncology literature. It usually resolves, however, there are reports of potential mortality, and of course, morbidity while it is ongoing.If PRE...
Do you routinely isolate and test for TB in a patient incidentally found to have a miliary pattern of nodules on chest CT?
The short answer is yes. CDC recommends applying airborne isolation for any "suspected" case of TB. So if you suspect, you should isolate until you rule out with 3 negative AFB or have an alternative diagnosis. Keep in mind pretest probability and risk factors for that patient with the miliary patte...
Do you routinely monitor imaging or pulmonary function in patients with pulmonary TB after the completion of therapy?
The simple answer will be: NO.
Does your approach to treating latent tuberculosis differ in a patient on anti-fibrotic therapy?
With the increasingly common indication of progressive pulmonary fibrosis in the setting of CT-ILD, RA, and scleroderma, it is conceivable that patients being started on antifibrotic therapy may be on anti-TNF alpha or other immunosuppressive agents. Specifically with anti-TNF alpha agents such as R...
Do you check EPO levels in patients with anemia of chronic kidney disease?
No, I never check EPO levels in patients with anemia of CKD since they're uninterpretable. Patients with CKD have inadequate EPO synthesis for their degree of anemia, so their EPO levels may be greater than normal yet still not sufficient to correct the anemia. We now understand the role of inflamma...
Are you using the microbial cell-free DNA “Karius” test to aid in the diagnosis of an atypical pulmonary infection such as PJP or NTM?
No, not at this time. Intriguing, but not sure we know enough yet.
How would you manage a middle-aged patient with Paget's disease who received one dose of zolendronic acid 2 years ago, currently suppressed CTX, normal bone-specific Alkaline phos, and a recent hairline fracture in the thoracic spine?
Parathyroid hormone analogs are, of course, contraindicated in patients with Paget's disease and I am not aware of any data regarding the use of romosozumab in patients with this condition. Paget's disease is primarily considered to be an osteoclast-related disorder and bisphosphonates, particularly...
How would you approach treating a patient with active rheumatoid arthritis and a history of treated lymphoma that is currently in remission?
I would individualize treatment in each patient depending on degree of RA activity, type of lymphoma and length of time of remission with shared decision-making between myself, patient and oncologist. For moderate to high degree of activity of RA, in general, rituximab in keeping with the ACR 2021 g...
How do you interpret the results of oligoclonal bands ordered to evaluate for demyelinating disease in patients with brain MRI lesions of unclear etiology?
While the presence of oligoclonal bands (OCBs) has been incorporated in the updated diagnostic criteria as a surrogate for dissemination in time, OCBs should not be used in isolation to make the diagnosis of multiple sclerosis. There are several systemic and peripheral immune diseases, including inf...