Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When do you stop immunosuppressants in patients with GPA?
It depends on the severity of the initial presenting symptoms and which organs were involved. However, generally, I don't stop all treatments and maintain the patient on at least MTX or azathioprine, potentially for life, even if these were not part of the initial remission-inducing regimen, such as...
Would you anticoagulate a patient with an isolated arterial thrombosis in the setting of an inherited thrombophilia?
The situations in which anticoagulation is clearly required in cases of arterial thrombosis are: stroke or systemic embolism in association with atrial fibrillation or mechanical heart valves or presence of a mural thrombus (where anticoagulation with an appropriate agent should be administered prop...
When sending patients for follow up chest CT's after SBRT or chemoRT, how do you determine whether to send for scans with or without IV contrast?
My rule for lung SBRT has been to minimize the use of contrast given the patient population we are treating (elderly, frail, and a desire to minimize kidney stressors), and the fact that we are following lung parenchymal lesions which are generally well visualized without contrast. I also have never...
How do you approach the decision of whether and when to initiate therapy in patients who remain COVID-19 positive >2 weeks after infection but are asymptomatic from the virus?
If the patient is asymptomatic or minimally symptomatic, we have elected to initiate therapy for the patient. We have treated the patient in full PPE at the end of the day with no other patients in the clinic. Efforts should be made to minimize patient contact throughout the clinic. We have the pat...
What is your next step in patients with polymyositis without interstitial lung disease who are refractory to methotrexate?
In general, first-line treatment for myositis patients includes methotrexate, azathioprine or CellCept. The exact choice of agent depends on concomitant manifestations of the disease, like lung disease or arthritis, and can move on to the next one if they fail one of them. At the same time though, w...
When do you use tacrolimus in patients with myositis-related interstitial lung disease?
Tacrolimus can be used as a first-line treatment for any myositis-related ILD; however, it does require more frequent monitoring than other agents. I usually use tacrolimus as a first-line treatment for MDA5-associated ILD given the published literature from Japan and China. In the majority of cases...
Do you continue hydroxychloroquine in lupus patients who develop cardiomyopathy?
The short answer is yes, in that most lupus patients with cardiomyopathy do not have hydroxychloroquine drug induced cardiac injury. That is to say most of these patients either have ischemic cardiomyopathy or non-drug NICM. With that said, antimalarials can produce adverse effects both on the cardi...
How do you manage oxaliplatin-induced acute peripheral nerve hyperexcitability?
This can be very frustrating for both the patient and the treating physician, as there is little that we can do to prevent this from happening. I have found that assurance is the most important thing that we can do for patients. For example, some patients can develop pharyngolaryngeal dysesthesias (...
Would you re-challenge patients who have had a TNF-associated paradoxical adverse event (such as inflammatory bowel disease) with a different TNF inhibitor?
I honestly have not heard of IBD as a paradoxical event with TNF inhibitors (unless possibly in a patient with underlying IBD that was not being treated adequately with etanercept rather than a monoclonal anti-TNF antibody). On the other hand, I have seen paradoxical psoriasis with TNF inhibitor use...
How do you manage patients who are Hepatitis B core antibody positive/surface antigen negative and starting a biologic DMARD (other than rituximab)?
According to the 2015 American College of Rheumatology Guidelines, a patient with natural immunity to Hepatitis B (Core & Surface Antibody-positive; Antigen-negative, normal liver function tests) can be treated as any other patient. However, monitoring of viral load is recommended "regularly" at 6-1...