Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Does serologic activity (e.g., high titer dsDNA, low complements) without clinical disease activity in a pregnant lupus patient affect maternal or fetal outcomes?
Not specifically. High titers of anti-dsDNA and low C3 and/or low C4, especially those that are adversely trending, are predictors of renal involvement which could adversely affect outcomes especially if the renal involvement mandates a change in therapy, but otherwise no. If these biomarkers are ab...
Are subcutaneous RA therapies less effective in obese patients?
Subcutaneous therapies may be less effective for RA in obese patients in some cases. The literature is mixed: no effect with subcutaneous abatacept but worse response in people with higher BMI with subcutaneous methotrexate.From personal experience, some obese patients or men with higher body weight...
Would you consider an osteoporosis medication in a pre-menopausal/young patient with a low Z score and an ongoing risk factor for secondary osteoporosis such as chronic antiepileptic treatment?
Osteoporosis prevention is always difficult in young patients with risk factors. For young premenopausal women or men below 40, I extrapolate from glucocorticoid-induced osteoporosis (GIOP) guidelines. If Z scores are below -3 and/or there is a history of fragility fracture(s), then treatment with O...
Is romosozumab an option in a patient who has completed 2 years of teriparatide therapy and has a fracture while on denosumab?
Romosozumab would be an excellent option in this setting. Although both teriparatide and romosozumab are anabolic agents, they have different MOAs and there is no cumulative time limit of therapy as there would be in the case of additional therapy with abaloparatide. At the completion of therapy wit...
Do you follow patients with elevated ESR/CRP if their work-up for rheumatologic etiology is unrevealing and no other cause is identified?
The short answer is yes for most cases. That said, there are many variables. Typically, elevations in acute phase reactants (ARPs) occur in response to different initiating events and can be observed to resolve on repeat testing. Persistent elevations in ARPs in the absence of clinical signs and sym...
What are the most effective therapies for CPPD with a "pseudo-RA" pattern?
That is a great question! The short answer is that we really don't know. There are no good quality RCTs for CPPD. In my experience, these patients are quite difficult to manage. I will often start with low dose prednisone (which almost always works) and then search for a steroid-sparing agent. I sta...
Are there any situations you would recommend prophylactic anticoagulation for a patient with Factor V heterozygosity?
In short, no. Thrombotic risk is a complex variable with many contributing components. The presence of a single FVL allele, while it appears to increase the risk somewhat, is not sufficiently predictive of overall risk to provide a basis for administering prophylactic anticoagulation in a clinical s...
What is your approach to gynecologic examinations/surveillance in a standard risk patient on adjuvant tamoxifen?
In the absence of symptoms (abnormal bleeding or discharge, pain, etc.), I do not recommend gynecologic examinations/surveillance beyond what is appropriate given the woman's age. First, premenopausal women on tamoxifen are not at increased risk of developing endometrial cancer. In postmenopausal wo...
Should tuberculosis screening be performed before beginning methotrexate for treatment of rheumatoid arthritis?
While it is not recommended or required to screen for latent TB (LTBI) prior to starting methotrexate, for many patients this may serve as a good opportunity to screen for LTBI, as many patients will go on to require biologic therapy due to incomplete response to methotrexate. There are many limitat...
How do you manage post-menopausal osteoporosis in a patient with stable bone density and no fractures after three years of holiday after giving zoledronic acid?
If the BMD is stable at three years of a post-treatment holiday, I would simply continue the holiday for another 1-2 years. The majority of post-menopausal women were able to achieve 5 years of treatment holiday before BMD dropped to baseline. Repeat the bone density measurement each year or two and...