Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach the concept of spondyloarthritis disease activity "burning out" and no longer requiring immunosuppression?
This is a difficult question to discuss academically, as we will have to accept a definition for “burning out,” which may or may not be synonymous with remission or a state that will support drug-free remission. That being stated, the possibility of spondyloarthritis going into remission (no “inflam...
Do you use buprenorphine in patients with chronic pain and prior history of opioid use disorder?
Absolutely. Buprenorphine is an excellent, evidence-based medication for patients with opioid use disorder, opioid use disorder with chronic pain, and chronic pain alone. The evidence in support of buprenorphine for pain has continued to accumulate over the past 10 years. At this point, I would neve...
Does the presence of psoriatic arthritis affect your decision to use an anti-IL-17 or IL-23 drug in your psoriasis patients?
I tend to prefer IL-17s in patients with PsA as an indirect assessment of clinical trials suggests they are more effective than IL-23s (which fits my clinical experience) for PsA. IL-17s are also more effective for axial disease (IL-23s are not very effective in axial disease). If there is a history...
When do you consider Cheyne-Stokes respirations noted in download data from positive pressure machines to be normal vs abnormal requiring intervention?
I do not have great confidence in the algorithms for CSR detection in CPAP machines (both in terms of false negatives and positives). That said, I agree with Dr. @Dr. First Last that if there is an newly increased amount of central events or CSR on a CPAP report, that should prompt (at the least) a ...
Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?
This is (and remains) a somewhat controversial question. ANCA titers do appear to rise in anticipation of disease flares and patients with persistent titers appear to have more flares. This is especially true for PR3 ANCAs. However, the proximity of flares to rising ANCA titers is not terribly close...
Do you use IL-1 inhibitors to prevent flares of gout or CPPD in patients who experience flares despite prophylaxis with colchicine, NSAIDs, and/or low-dose prednisone?
I have used IL-1 inhibitors to control gout flares or gout flare recurrences in patients who have been refractory to standard gout flare or gout flare prophylaxis management. Likewise, on extremely rare occasions, I have used an IL-1 inhibitor for recurrent CPPD flares, though with mixed results.The...
Outside of teplizumab, what therapies do you recommend for preserving beta cell function in patients with early stage type 1 diabetes mellitus?
Teplizumab is indicated to delay the progression of Stage 2 (hyperglycemia short of diabetes and 2 or more positive pancreatic islet cell antibodies) to Stage 3 diabetes--delayed the median time to onset of Stage 3 T1D by about 2 years longer than placebo in Stage 2 patients. I am not aware of stud...
What approaches have you found most helpful for concurrent severe major depressive disorder and alcohol use disorder?
I'm a strong believer in AA for alcoholics, to address the addiction and also the depression, as the social support offered there can be very helpful. A person agreeing to "work the steps" with a sponsor has more in-depth character restructuring and available support than most therapists can provide...
Should all patients with suspected giant cell arteritis get a PET scan to look for large vessel disease?
PET-CT and PET-MRI can be very useful diagnostic modalities in GCA, but I do not recommend universal screening with PET scanning. The upcoming ACR/VF sponsored vasculitis guidelines will likely recommend obtaining non-invasive vascular imaging to evaluate for large vessel involvement, but the recom...
How do you weigh the risks and benefits of GLP-1 RAs in patients over age 65 specifically in regards to loss of muscle mass and osteoporosis?
This is indeed a crucial question: rapid weight loss is accompanied not only by a loss of adipose tissue but also by a loss of lean mass, including muscle and bone tissue. This must therefore be taken into account when making decisions, particularly in patients with osteoporosis, frailty, sarcopenic...