Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When would you recommended restarting biologic medications in an active RA patient after treatment with monoclonal antibodies, convalescent plasma or antiviral medications for a COVID-19 infection?
As rheumatologists, we are accustomed to medical decision making in data free zones. This is what we face here too. There are no studies that have directly addressed these issues- nonetheless, the likelihood of meaningful drug interactions between a biological drug for RA and these various anti-vira...
How can healthcare providers better serve as allies of the sickle cell community?
Yes, the medical community should absolutely advocate for our patients with sickle cell disease (SCD). The vast majority of Americans with SCD are of African or Hispanic descent, and the overlay of racial inequality and healthcare disparities negatively impact their health outcomes (1-5). In additio...
How do you approach dosage changes of allopurinol as a patient's GFR decreases over time?
Usually, there is no need to adjust the allopurinol dose for a gradual decline in GFR with aging. The renal dose adjustment for allopurinol is for the initial dose of allopurinol to potentially reduce the risk of allopurinol hypersensitivity (Stamp et al., PMID 22488501). To my knowledge, there are ...
Should patients receive thrombophilia testing in the setting of a provoked VTE secondary to hormonal therapy/OCPs?
Given that oral contraceptives are considered a provoking event (Ortel et al., PMID 33007077), ASH Choosing Wisely guidelines recommend against thrombophilia testing since the recommended duration of anticoagulation is only 3 months. (Hicks et al., PMID 24307720 & Hicks et al., PMID 25472968).
Is there a role for regular hepatitis and TB screening in patients on chronic immunosuppressive therapy in the absence of new risk factors or exposures?
Unless there has been an interval introduction of new risk factor for TB or hepatitis B, there is no need to screen annually and baseline testing is adequate.
Would you consider using teriparatide beyond a cumulative maximum of two years now that the black box warning regarding osteosarcoma has been removed?
This is a very good question. Early studies with PTH compounds for osteoporosis showed you could give it for three years and still have an effect on increasing bone mass. The black box warning was for osteosarcomas that occur in young adults and children, and the black box warning was also for indiv...
Would you consider tamoxifen to be contraindicated for chemoprevention in patients with a history of OCP induced VTE?
Absolutely, yes. SERMs are contraindicated in women who have a history of thrombosis and in women who are pregnant, planning to become pregnant, or are breastfeeding. SERMs are also relatively contraindicated in patients with increased risk of thrombosis, such as those who smoke or have a familial p...
Would you ever consider prophylactic anticoagulation in patients with CKD requiring ESA therapy?
I would not start anticoagulation in this setting solely because the patient is to receive ESA treatment, but would advocate for adjusting the ESA dose to maintain a hemoglobin of 9-10 g/dL, since a number of studies suggest that targeting higher hemoglobin levels is associated with increased risk o...
How do you approach immunosuppression targeting skin thickening in scleroderma after the initial three years of onset?
I think there is still a role for trial of immunosuppression in the case of a patient who has diffuse skin disease and has signs of progression or lack of improvement even if it is beyond 3 years. If a patient has limited skin distribution (i.e., only sclerodactyly) or the skin has not changed over ...
How do you counsel patients on JAK inhibitors about the risk of venous thromboembolism, MACE, and cancer?
I advise patients that there remain many unanswered questions regarding these side effects that will be resolved with longer term use with these agents. Shared decision-making is critical for these discussions. Data available from current extensions of clinical trials for JAKi, additional risk facto...