Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In a patient with Type I von Willebrand disease with history of VTE and heavy menses, would tranexamic acid be a treatment option?
Why not try hormonal IUD or implant as long as the patient is willing to try (as almost no risk of thrombosis)?
How do you manage hyponatremia in patients with renal cell carcinoma on cabozantinib and nivolumab?
Since ICPI can cause thyroiditis and adrenal insufficiency, the TSH and AM cortisol should be checked -- in addition to the usual evaluation for hyponatremia (serum and urine Osm, urine electrolytes, and an assessment of the patient's volume status). If adrenal insufficiency is present, the hyponatr...
How do you approach work-up for a patient suspected for monoclonal gammopathy of renal significance for whom renal biopsy is contraindicated?
Not very many reasons that a renal biopsy could not be done, but I would consider doing a bone marrow biopsy if the free light chain ratio was significantly abnormal, i.e. a ratio of 3 or greater. A reminder that in renal failure, both light chains may be elevated, but the ratio in benign processes ...
How do you explain TTP to patients?
I tell them there is an enzyme in their blood called ADAMTS13 that helps keep their platelets from sticking together and plugging small blood vessels, and that for unknown reasons, their own immune system is destroying this enzyme. The symptoms of TTP are caused by clumps of stuck-together platelets...
Do you recommend continuous antibiotic prophylaxis for patients on complement inhibitors such as eculizumab?
This is an extremely important and timely question. There simply isn’t enough data or firm guidelines on this leading to different practices. The reality is that there have been a number of meningococcal breakthrough infections in those vaccinated against meningococcal disease. Complement therapies ...
For a rectal cancer with questionable T3 or questionable N+ by MRI, can short course radiation be given followed by surgery and the pathology still be interpreted to guide adjuvant chemotherapy?
This is a somewhat common scenario. In these situations, I have strongly favored short course RT followed by immediate surgery such that there is not a sufficient time interval between RT and surgery to allow any significant pathologic response. I think you can be confident in that the pathology aft...
How do you manage dermatomyositis related to underlying malignancy?
Treat underlying malignancy with urgency Steroid + IVIG is the best treatment for dermatomyositis with active malignancy.
How do you manage a case of dermatomyositis that is proven on skin biopsy and clinically has proximal muscle weakness but normal muscle enzymes, including CK, aldolase?
About 20-30% of Active Dermatomyositis patients may have normal muscle enzyme level. Also, sometimes muscle enzymes other than CK and aldolase are elevated such as LDH, AST and ALT. So check all 5 muscle enzymes. Can also do EMG or MRI or muscle biopsy to confirm muscle involvement. First line trea...
How would you treat active rheumatoid arthritis in a patient in complete response on loralatinib for stage IV ALK positive NSCLC?
I would do my best to minimize immunosuppression. I would use IL-6 or Abatacept and possibly rituximab. Have done all to minimize DMARDs and have had success with all 3.
Do you continue to utilize ESR and CRP in patients on tocilizumab?
Yes, it is still worthwhile getting these tests. Anti-Il-6 therapy will reduce CRP and ESR values to very low levels, so when a result returns higher than expected, it may imply limited compliance with the drug. In some patients with very high CRP values at baseline, the CRP may take some time to re...