Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage hand-foot syndrome associated with capecitabine (and other conventional chemotherapy agents)?
In the breast cancer world, I see hand-foot syndrome most commonly with capecitabine. I have used topical 10% urea cream with a reasonable amount of success. I have noticed that using it prophylactically seems to help with the prevention of hand-foot syndrome to quite an extent. A couple of randomiz...
How do you manage early rectal symptoms such as tenesmus in a patient undergoing pelvic radiation for prostate cancer?
If patients are having symptoms out of proportion to what you would expect, I consider other potential causes, especially if the usual management approaches aren't working. I've had a few patients over the years with undiagnosed Celiac disease, who got severe early diarrhea during a course of extern...
Which immunosuppressed patients with SLE would benefit from antibiotic prophylaxis to prevent pneumocystis pneumonia?
Starting PCP prophylaxis in patients with lupus is controversial. We typically start lupus patients on PCP prophylaxis if they have underlying ILD and are on doses of steroids of 20 mg or higher. I also consider starting PCP prophylaxis in lupus patients while they are receiving cyclophosphamide and...
Should venous thrombosis in a patient with Behcet syndrome be treated with both immunosuppression and anticoagulation?
They should be treated with immunosuppressive medications, however, the additional benefit of anticoagulation is much debated. Various studies and metaanalysis have shown that anticoagulation, on average, does not add any benefit. There may be exceptions to this in the early part of treatment for so...
Is there a role for PCSK9 inhibitors in patients with statin-associated immune mediated necrotizing myopathy?
The majority of patients with statin-associated immune mediated necrotizing myopathy are in need of cholesterol-lowering medications. While one can try other strategies (like diet or ezetimibe), these are usually inadequate. Therefore, I would advocate for PCSK9 inhibitors as first-line treatment, w...
What is your approach to treating refractory thrombocytopenia in lupus?
Refractory thrombocytopenia is challenging to treat. It is important to evaluate for non-SLE causes including infection, medications, and malignancy. It is also important to differentiate ITP from TTP/atypical HUS. Once the ITP diagnosis is confirmed, I usually don't treat asymptomatic thrombocytop...
Are there particular concerns related to the use of B-cell depletion therapies such as rituximab for rheumatic disease during the COVID-19 pandemic?
The attendant depletion of CD20+ B cells associated with treatment with rituximab likely results in impaired development of host immunity to previously unrecognized microbial pathogens. This has, therefore, been of concern in the context of the Covid-19 pandemic due to potential greater adverse outc...
How does the presence of myositis alter your interpretation of cardiac enzymes when evaluating acute chest pain?
Troponin T and CK-MB are not reliable for cardiac issues in myositis as regenerating muscles produce these enzymes. This is especially true if the patient has an active disease with weakness and CK elevation. Troponin I is not much affected by muscle enzymes and should be used as a parameter to eval...
How do you approach diagnosing a patient with Iron Refractory Iron Deficiency Anemia (IRIDA)?
Iron-Refractory Iron Deficiency Anemia should be suspected when there is a lack of response to oral iron and only a partial response to intravenous iron. One should make sure there is not a chronic underlying inflammatory process to explain the lack of iron absorption or lack of the expected respons...
Do hemoglobin S levels always correlate with SCD phenotype?
The severity of sickle cell disease (SCD) is usually associated with the level of hemoglobin S (HbS). For example, HbSS and HbSB0 thalassemia, which generally have higher HbS levels, are usually more severe than HbSC and HbSB+ thalassemia. While patients with HbSC and HbSB+ thalassemia typically hav...