Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What agent would you choose for a patient who needs osteoporosis therapy after a bisphosphonate holiday?
This is a question of high clinical importance but with a lack of good controlled data. First and foremost, a holiday should be viewed as a temporary discontinuation of therapy. Anecdotally, I would say about 30% of my patients need to go back on therapy. There is a lack of data to support clinical ...
In patients with knee osteoarthritis, do you recommend the use of hyaluronate injections if it is available and affordable for the patient?
This is a very controversial topic because the data simply hasn't been convincing. Many professional medical societies have either rejected HA or recommended it conditionally (or recommended against it conditionally). That being said, the literature has plenty of case series and reports of great rel...
Do you use hydroxychloroquine for prevention of neonatal lupus in patients with a positive SSA who are planning on becoming pregnant?
There is some evidence that hydroxychloroquine can prevent CHB in patients at high risk (mothers who already had a fetus with CHB in a previous pregnancy (Izmirly et al., PMID 32674792). There is scant evidence about neonatal lupus and the use of HCQ to prevent it. HCQ is generally well-tolerated an...
Is chronic major salivary gland enlargement in a patient with Sjogren's an indication for immune-modulating therapy such as hydroxychloroquine or methotrexate?
Although there have been 2 patients reported to have an improvement in parotid size with hydroxychloroquine and methotrexate are generally ineffective for the treatment of chronic bilateral major salivary gland enlargement in Sjogren's. For acute bilateral swelling, a tapering dose of prednisone can...
How do you counsel patients who ask you about trying oral or topical formulations of medical marijuana for pain related to arthritis or fibromyalgia?
Despite the acknowledged widespread use of cannabis in rheumatology patients, there has been no evidence of its efficacy. A recent systematic review of randomized controlled trials found no evidence for the use of cannabinoids, cannabis, and cannabis-based medications in chronic pain management (Fis...
How would you manage a patient with profound dyspareunia after pelvic radiation for anal cancer?
Thanks for bringing up this important topic that remains understudied, with historically widely underestimated incidences of post-radiotherapy dyspareunia. There is currently no standardized method or schedule for assessing post-treatment sexual dysfunction including vaginal stenosis and fibrosis (a...
What baseline work-up do you do for patients with suspected palindromic rheumatism?
I'm sure this varies a lot by rheumatologists. For someone with a pattern of recurrent and episodic arthritis that sounds inflammatory, I think the differential diagnosis should include rheumatoid arthritis, gout, and calcium pyrophosphate deposition disease, polymyalgia rheumatica, and perhaps some...
How do you manage severe vaginal dryness and vulvodynia refractory to topical lubricants in patients with Sjogren's syndrome?
Exclude candida, vestibular gland blockage, and lichen sclerosis.First-line treatment option is vaginal estrogens (cream, ring) or low-dose systemic estrogen (tablet, patch).Second-line options include vaginal DHEA or vaginal testosterone.The severe vaginal dryness in Sjogren's is associated with ly...
How do you approach the pharmacologic management of cancer-related fatigue?
After the above considerations mentioned in the question, management considerations regarding cancer-related fatigue depend on the stage of disease (advanced/metastatic disease vs not) and whether the patient is on active cancer therapy. For both groups, non-pharmacologic interventions have the high...
Is there a role for tocilizumab in treatment of polymyalgia rheumatica in patients who do not have features of giant cell arteritis or rheumatoid arthritis?
In select PMR patients with multiple relapses as corticosteroids are tapered or who have significant steroid toxicity, additional "steroid-sparing" agents may be considered. I do think in this setting tocilizumab may be useful. IL-6 has long been appreciated as a pivotal cytokine in PMR. Two studies...