Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is it ever reasonable to switch to a different TNFi as opposed to switching to an agent in a different class in a case of TNFi induced lupus or psoriasis?
This is a very interesting question where the answer continues to evolve. I would also like to answer the question separately. Both Psoriatic skin lesions and lupus or lupus-like conditions can be induced by anti-TNF-alpha therapy. The pathogenesis may involve changes in cytokine balance.Regarding P...
How long would you treat with antimycobacterials before starting biologic DMARD in a patient with latent TB and active rheumatoid arthritis?
This is a common question rheumatologists ask their ID colleagues. Given the diversity of patient presentations, though, there isn't a blanket answer. One reason there's no blanket answer is because it is so hard to study LTBI risks, due to infrequent conversion to active TB, which is a fortunate th...
How do you approach management of sickle cell patients who mistrust Western medicine and prefer naturopathic therapies?
With compassion and understanding, I would explain that the lifespan of patients with SCD in regions with access to Western medicine far exceeds that where the disease is most prevalent. Controlled clinical trials have proven the utility of hydroxyurea to alter beneficially the course of disease and...
How do you tailor seizure medications in patients who become pregnant or are family planning?
There are basic guidelines for planning pregnancy: folate 4 mg QD, good prenatal care. All seizure medications are basically comparable except valproate as far as birth malformation. Monotherapy if possible, and low dose if possible. Modern medications are generally preferred over old ones. For the ...
For patients with post-stroke headaches, what treatment do you typically recommend?
First off, I usually recommend treating the headache based on phenotype. So if the headache meets ICHD-3 criteria for migraine, then treat as migraine.Great resource for current treatment recommendation in general for migraine: Ailani et al., PMID 34160823.In terms of considerations specific for str...
In which patients with autoimmune or inflammatory conditions are you recommending a 3rd dose of the mRNA COVID vaccine?
We found that many of the patients on immune suppressive medications do not have an appropriate response to the initial 2 doses of mRNA COVID19 vaccines. At this point, I recommend a 3rd dose to all the patients on immune suppressive medications, prioritizing the ones with known low titers of SARS-C...
In the rare setting of enoxaparin injection-induced abdominal wall hematoma in patients requiring long-term anticoagulation, what is your timeline for restarting anticoagulation?
Abdominal wall hematomas typically occur when a vessel has inadvertently been injured during injection. Timing of resumption of anticoagulant will vary with the underlying indication for anticoagulants. For a high-risk indication, eg multiple cardiac valves in patients with history of stroke, I woul...
What is your approach to the management of hot flashes in a patient who wants to use herbal medicine?
Hot flashes are so bothersome to some postmenopausal women, especially those with breast cancer in whom we discourage the use of estrogen or potentially estrogenic, that we now have evidence from randomized trials to help guide treatment. With regard to nonprescription therapies, data thus far suppo...
What is your approach to a patient with rheumatoid arthritis and moderate disease activity on 25 mg of PO methotrexate?
Switching to sub cu may work for low disease activity, but not moderate.
How do you approach treatment of osteoporosis in patients with CKD who develop a fragility fracture while on denosumab?
The only option left at this point is a PTH compound. Please it or not, it still works every time in subjects with a secondary elevation of PTH. I would try either Forteo or Tymlos for a few months and see if the patient can tolerate it and if the calcium numbers remain stable. I am not sure about r...