Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach localized lymphadenopathy in a patient with lupus whose symptoms are otherwise well-controlled?
Localized adenopathy in lupus is infrequent and the differential is broad including nonspecific reactive hyperplasia as part of underlying illness or local trigger, infectious (e.g., suppurative in association with staph or strep, MTB, atypical mycobacterium, fungal, etc), lymphoma (e.g., Hodgkin's ...
How many years of oral antibiotics prophylaxis do you recommend for a teenager with hereditary spherocytosis post-splenectomy?
If older than 5 and vaccinated, no proph.
For patients on a bone-modifying agent for osteoporosis/severe osteopenia in the context of adjuvant AI therapy, how do you manage the bone-modifying agent once their AI course is complete?
In this case, I would be guided by the bone density (DXA) scan, if there is still osteoporosis or severe osteopenia, I would continue the BMA and repeat the DXA scan in one or two years. If the DXA shows improvement, I would discontinue the BMA, knowing that one can re-institute at a later date. Sev...
What treatment options are available for patients with spondyloarthritis who develop biologic-induced psoriasis?
Management of patients in these situations is quite challenging and the approach should be individualized. Biologic induced psoriasis is most commonly seen with TNF-α inhibitors as a paradoxical response. However, this has also been rarely described with other biologic agents: Interleukin-6 blockers...
How do you manage arthralgias with subclinical synovitis seen on US or MRI?
The holy grail of rheumatology is to prevent the onset of clinically apparent arthritis as most leaders in the field believe that early treatment may prevent onset of overt arthritis and lead to drug-free remission. Unfortunately, the issue is much more complex than imaging alone to define early dis...
In patients with autoimmune cytopenias, is there any reservation for COVID vaccination?
No... benefit outweighs risk. Evidence of benefit (and its magnitude) is clear without proven evidence of risk in this population (save for potential for increased bruising in setting of severe thrombocytopenia).
Do you consider low-dose aspirin for primary thromboprophylaxis in patients with high-risk antiphospholipid antibody profiles?
Yes, I offer low dose aspirin for patients with high titer anti phospholipid antibodies. The patients often agree unless they are concerned of increased risk of bleeding due to their profession or hobbies, such as horseback riding. I do not recall such adverse events. Nevertheless, controlled trials...
What is your preferred oral iron formulation and dosing for treatment of iron deficiency anemia?
I recommend using ferrous sulfate given either every other day or twice weekly. (Powers and Auerbach, PMID 32844200)
How do you manage endocrine therapy in patients on tamoxifen who develop thrombophlebitis but not DVT?
In a patient on tamoxifen, the risk of clot extension into the deep system is higher than average. In such scenarios, the recommendation is to use anticoagulation for at least 6 weeks (consider 3 months if no improvement noted at 6 weeks). Tamoxifen should be held for the first 3 weeks, consider res...
How would you manage methotrexate therapy in an active rheumatoid arthritis patient undergoing treatment for latent TB with rifampin?
There are no easy answers as both rifampin and INH combined with methotrexate are associated with enhanced hepatotoxicity. Monotherapy regimens, while generally well tolerated can cause hepatotoxicity leading to dose modification/interruption in about 5-10%. All approved regimens can be tried depen...