Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should patients with bleeding disorders increase their home supplies of clotting factors foreseeing a possible shortage of product availability due to COVID-19?
No. The Medical and Scientific Advisory Council (MASAC) for the World Federation of Hemophilia recommends against increasing the already recommended home supply of clotting factors: One month worth of regular prophylaxis doses if on a prophylactic regimen; and one major correction dose, and two mino...
What lifestyle changes (if any) do you recommend to patients and caregivers regarding the bodily fluids of patients receiving systemic therapy?
For recommendations related to reproduction (both genders) and lactation, the USPI (a.k.a. FDA label) is a great place to start. Specifically, I refer to subsections 8.1 Pregnancy, 8.2 Lactation, and 8.3 Females and Males of Reproductive Potential of the "Use in Specific Populations" section. These ...
Do you adjust PSA for finasteride use when determining prostate cancer stage and risk category?
We generally use the rule of 50% (real PSA is twice the lab value when on Finasteride).
How long after discontinuation of TKI (for complete remission) would you feel it is safe for a patient with CML to consider pregnancy?
Tyrosine kinase inhibitors have been demonstrated, in animal models, to be teratogenic when utilized early in pregnancy. In retrospective studies in humans, congenital anomalies similar to what was identified in animal studies have been reported. Since spermatogenesis takes several weeks, some have ...
Are you recommending aspirin in breast cancer survivors?
I do not recommend aspirin in breast cancer survivors routinely. The role of aspirin in terms of improving survival is not clear yet- with some observational studies showing a benefit but no prospective high level evidence. There are a couple of large studies looking at this. There are various intri...
Do you recommend that children with sickle cell disease refrain from returning to school during the COVID-19 pandemic?
If schools are open and there is no special infectious risk at the school in question, then it would likely be appropriate to send your child with sickle cell anemia to school. There is no evidence of extra risk of COVD in patients who have had an autosplenectomy and no evidence of particular proble...
Is it okay to use COX-2 selective NSAIDs in patients with IBD-associated arthritis when the IBD is in remission?
I do not feel comfortable prescribing COX-2 NSAIDS to patients with IBD in remission. If I have such a patient and an NSAID is the major therapeutic option, I will reach out to the treating gastroenterologist for an opinion on whether this is advisable.
Should patients be screened for hepatitis B/C prior to starting a conventional synthetic DMARD such as methotrexate?
If you are even thinking about it, YES!!!!AASLD suggests HBV screening when contemplating immunosuppression with HBsAg, anti-HBcore, and anti-HBs for immunization status (separate issue). HCV-Ab should be done at the same time as I have advocated for many years, but now, the practice is catching up ...
Do you regularly do bone density testing to screen for osteoporosis in men with rheumatoid arthritis without any other risk factors?
An important comorbidity in RA is fragility fractures. These patients are at higher risk of OP because of increased pro-inflammatory cytokines and glucocorticoid treatment. OP screening strategies are both feasible and effective in RA patients and recommended by most specialty organizations. Both me...
In which osteoporosis patients would you consider starting with anabolic therapy over antiresorptive therapy?
Anabolic therapies including teriparatide (PTH-analog), abaloparatide (PTHrP-analog), and romosozumab (anti-sclerostin) are all indicated for patients with osteoporosis and high fracture risk. Although denosumab (anti-RANKL) is an antiresorptive agent, it also leads to significant bone gain similar ...