Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Are there any known contraindications for IL-23 use in patients with psoriatic arthritis and CKD or ESRD?
There are no contraindications in the use of IL-23 inhibitors in the treatment of psoriatic arthritis. The package insert suggests no dosage adjustments for CKD. Clearance of a monoclonal ab is through degradation to small peptides and amino acids in a fashion similar to endogenous IgG. My only conc...
How would you work up focal periventricular leukomalacia presenting in adulthood?
This depends on the location, appearance, size, and PMH of the patient. However, I usually start with giving contrast (aware it is encephalomalacia) and as known, most won't enhance. What is the age of this adult patient? Is there any previous history to suggest MS? If ischemic, why did it happen? D...
What has been your experience using apremilast to treat mild to moderate psoriatic arthritis not controlled with NSAIDs?
Overall, my experience has been good with apremilast when the correct patient is targeted for therapy. The best patient generally falls into a niche of milder disease. Mild to moderate psoriasis and milder and less aggressive MSK manifestations. Patients need to realize that they are trading speed o...
In a patient with a heterozygous prothrombin gene mutation who has COVID with minimal symptoms, do you recommend prophylactic and/or therapeutic anticoagulation?
If the patient has no history of VTE, I would not recommend any anticoagulant treatment. Heterozygous prothrombin G20210A polymorphism is a relatively weak risk factor for VTE in comparison to antithrombin, protein C, or protein S deficiency, and in general, is not a finding that should guide decisi...
What bDMARD would you choose for a patient with RA with high infection risk and inadequate response to cDMARDs?
This is an important question and a prime example of the "art of rheumatology" where we must balance the risk and benefit of targeted therapies of treating active RA and adverse events such as serious infection. Ideally, we would have many head-to-head trials of every agent adequately powered to ans...
Would you advise a patient with quiescent vasculitis who flared with the first Covid mRNA vaccine to obtain an additional dose?
There is still much we don't know about mRNA vaccines, including the true risk of vasculitis relapse and the risk of relapses occurring with vaccine re-challenge. Relapses of vasculitis after COVID vaccination have only been reported in case report form to date. Therefore it's not possible to tell w...
Should a pregnant woman who is heterozygous for factor V Leiden who has never had a thrombotic event receive prophylactic anticoagulation?
This is a common situation and lacks evidence based recommendations. Recent ASH guidelines (Bates et al., PMID 30482767) suggest against routine antepartum prophylaxis in this situation. However, it is important to have a balanced discussion with the patient. In my experience, most would choose prop...
How would you approach breast cancer screening in an adolescent patient with a CDH1 mutation?
The timing of initiation of breast cancer screening in an adolescent female with a germline CDH1 pathogenic variant will depend on family history. Initially, I follow the NCCN guidelines which recommend starting screening mammograms +/- breast MRIs annually at age 30. If there is a family history of...
Is there any utility in checking HLA-B*5801 in our Black and Asian patients who are already tolerating allopurinol?
I don't believe there is any value in checking HLA0B*5801 once the patient has been on allopurinol therapy for several weeks or months as allergic reactions, particularly SJS and TENS, occur within the first few weeks of treatment. Further, a positive test, weeks to months after beginning allopurino...
What are the best treatment options for persistent post-traumatic headaches when first line agents like TCAs have failed?
Would treat post-traumatic headache according to the primary headache disorder phenotype.Post-traumatic headaches statistically most often have a migraine disorder phenotype. So if one does not respond to TCA as a preventative medication then I would consider other migraine disorder preventative med...