Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What immunosuppressive agents aside from steroids would you use to treat bronchiolitis obliterans in a patient with long-standing seropositive RA?
There is little doubt that bronchiolitis obliterans can be a devastating lung disease. Corticosteroids remain the primary anchor therapy, however, virtually all patients will require an additional agent. Rituximab has become the primary choice and there is evidence, though mostly anecdotal, that it ...
How do you approach screening for inflammatory bowel disease prior to starting IL-17 inhibitors?
IL-17i are now widely used to treat skin psoriasis (PsO), psoriatic arthritis (PsA), and axial spondyloarthritis (SpA). Genetic and epidemiologic studies suggest the coincidence of these diseases and Crohn’s diseases (CD) as they may present concomitantly in the same patient or affect a family membe...
Is there a role for antibody testing to confirm vaccine response for patients on rituximab after COVID-19 vaccination?
It's a great question, but I do not feel that routinely performing COVID antibody testing would help in the management of these patients: We don't know how well most commercial antibody testing correlates with neutralizing antibody/immune-status (esp. if qualitative testing is performed), and I have...
How do you approach evaluation of pulmonary vein thrombosis?
Pulmonary vein thrombosis is a rare condition that is usually associated with injury to the vessel, for example after surgery or lung transplantation, or as a complication of lung cancer. I am not aware of any data on the relative efficacy of different anticoagulants in PVT but from a biologic persp...
Do you routinely obtain bone marrow biopsy in newly diagnosed autoimmune hemolytic anemia when working up potential underlying etiologies?
Thank you for the question. For patients with cold agglutin disease, I perform a bone marrow biopsy and flow cytometry at diagnosis/before initiating therapy on all patients. I base the decision whether to do a bone marrow biopsy after initial diagnosis of warm autoimmune hemolytic anemia based on w...
Does calcinosis appear differently in patients with dermatomyositis compared to systemic sclerosis?
Classically, calcinosis in dermatomyositis and scleroderma are different with dermatomyositis having more typical sheet-like calcinosis in the muscles whereas in scleroderma it is more typical on the fingers, extensor surfaces of the forearm, olecranon, knee, and shins. However, many sclerodermas al...
How does evidence of cerebral amyloid angiopathy/microbleeds affect choices for secondary stroke prevention in patients with a history of ischemic stroke and atrial fibrillation?
This is a discussion I have with the patient, mentioning that the positive predictive value of cortically based cerebral microhemorrhages is not absolute, especially when there is a small number of them and there are no other signs of small vessel disease (such as FLAIR changes or enlarged peri-vasc...
What is your approach to immunotherapy-related pancreatitis?
Depending on the severity of the ICI-associated pancreatitis, I will start patients on prednisone 0.5 mg/kg/day - 1 mg/kg/day. Once lipase levels decrease and approach normal levels, I will start tapering at generally around 10 mg weekly with a total taper time that is typically close to 6 weeks. If...
How do you approach the treatment of eosinophilic fasciitis refractory to glucocorticoids and methotrexate?
As rheumatologists, we are accustomed to managing people with rare diseases. Eosinophilic fasciitis (EF) ranks among the rarest of the rare, so it is understandable that there are no carefully designed trials assessing the efficacy of the various immune-modulating drugs. Clearly, corticosteroids are...
Are there any specific circumstances when you would consider the use of immunosuppression for DISH?
DISH and SpA are two separate pathological entities that share involvement of the axial skeleton and peripheral entheses. Both diseases cause bone proliferation in the spine and extraspinal entheseal sites, particularly in the later phases of the disease.DISH is characterized by calcification and os...