Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?
Our hematologist/oncologist referred just such a patient. No evidence of malignancy, but elevated CRP &ESR. I did an “internist’s” workup as I would for dermatomyositis, starting with the most important and therefore most thorough aspect: taking a full and very “invasive” history, followed by a comp...
What is your approach to the diagnosis and management of lupus cystitis?
Lupus cystitis is a rare complication of lupus but there does appear to be an association. I depend on the urologist to confirm the diagnosis of interstitial cystitis. If mild to moderate in activity, will use standard treatments for cystitis with bladder infusions, bladder relaxants in collaboratio...
What labs do you order to monitor patients on JAK1 inhibitiors (abrocitinib or upadacitinib)?
TB, HepB, and HepC at baseline, never repeated. CBC, CMP, and Lipids at baseline and 3 months, then once a year. CMP is probably unnecessary - no hepatic or renal toxicity - but I still do it. WBC and Hemoglobin often go down a little bit, but always happens in the first 3 months. Have had 2 patient...
What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?
This is an important concept because anyone using tocilizumab will eventually wrestle with this question. The question, though, does not tell you whether this is the first time a practitioner sees the liver enzyme elevation, or how high the liver enzymes rose. Since everyone should have had a lipid ...
Does your approach to the management of a patient with an acute exacerbation of CPFE where the ILD is attributed to IPF differ from the management of a patient with an exacerbation of IPF alone?
In general, once an extensive workup to exonerate alternative causes of ILD in patients with presumed CPFE has been performed, I tend to treat the interstitial component of these two entities similarly, whether in the chronic phase or during an acute exacerbation. Smoking is a well-known risk facto...
How should elevated PT of unclear etiology and significance be evaluated?
Mild prolongation of the prothrombin time (PT) may represent a normal ‘outlier’. If there is no obvious explanation for a moderate to marked prolongation of the PT (for example, anticoagulation therapy effect, liver disease, nutritional deficiency like vitamin K deficiency. then the next step is to ...
When is the index of suspicion high for paraneoplastic systemic sclerosis in terms of clinical and serological presentation and how will you work it up?
This is a great question. Data on the risk for malignancy in newly diagnosed scleroderma patients has been emerging for the past 10 years or so. To date, it appears that the strongest risk factors may be autoantibody with RNA polymerase 3 antibodies showing consistent increase in risk amongst sclero...
What is your approach to patients who present with unilateral Raynaud's?
Thank you for that excellent question! Typically, Raynaud’s phenomenon impacts multiple digits of both hands (and often feet; sometimes tip of the nose, ears, nipples) and is often symmetric in the case of primary and can be asymmetric in Secondary Raynaud’s (often sparing the thumb). In some cases,...
How do you recommend tapering IVIG in patients whose inflammatory myositis has achieved remission?
This is a very good question without any right or wrong answer. My practice is to start tapering the IVIG 6 months after the patient has achieved clinical remission. I usually start decreasing the dose of the IVIG, but the other option is to extend the interval between the patient's infusions. The e...
How would you counsel a patient with active SLE on treatment, low to moderate level of one of the APLS antibodies, and remote history of provoked blood clot regarding perioperative anticoagulation?
Without knowing more specific details, my approach would be to repeat the full panel of antiphospholipid antibodies, institute treatment with HCQ if not there already, discontinue all estrogen products and counsel the patient against smoking. I would coordinate perioperative anticoagulation with a h...