Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you use aspirin 81 mg for VTE prophylaxis in patients on adjuvant tamoxifen/SERMs?
In a meta-analysis of over 30,000 patients, VTE was found in 2.8% of patients on tamoxifen and 1.6% of patients on AI. So, yes there is a higher risk of VTE on tamoxifen but the percentage is still very low. I would not use 81 mg aspirin as VTE prophylaxis in all patients on tamoxifen to rescue or p...
Do you provide prophylactic anticoagulation with abemaciclib in the adjuvant setting given known thrombosis risk?
I don’t generally recommend prophylactic anticoagulation with abema, either in the adjuvant or metastatic setting. There does appear to be a small, but real, incidence of thrombosis associated with abema, as well as the other CDK 4/6 inhibitors. While this risk is quite uncommon, it is important cer...
How would you approach a postmenopausal woman with Stage I HR+,HER2- breast cancer who had a CVA while on tamoxifen?
A major co-morbidity such as a stroke should prompt a re evaluation of the benefit risk ratio and overall value of adjuvant endocrine therapy, especially for low risk disease. It would be helpful to unpack this situation a little more. How bad is the stroke and how much loss of mobility and performa...
How would you approach diagnosis of residual ovarian tissue in a patient with ER positive breast cancer, history of BSO, and a rising estradiol level on tamoxifen?
Diagnosing elevated estrogen levels in a patient who has undergone BSO is difficult, since the symptoms are typically very non-specific (e.g., improvement in hot flashes, change in mood). There are multiple potential reasons for elevated estrogen levels following BSO, including an adrenal tumor that...
How would you manage adjuvant endocrine therapy for a postmenopausal patient with early stage HR+ breast CA who develops an ischemic CVA on an AI?
This is a vexing problem that I myself have had to deal with. My patient developed a TIA on aromatase inhibitor (AI). Work up was negative for predisposing risk factors. The choice was easy in this case. This woman was told by her family friend, who was a doctor, that AIs cause stroke and she refuse...
In which scenarios do you use vaginal estrogen in patients with history of HR positive breast cancer?
A recent study (McVicker et al., PMID 37917089) supports the likely safety of vaginal estrogens in breast cancer survivors. Limitations of this study are that it primarily included lower-risk individuals with stage I-II disease and women 50+. In addition, the level of data is limited by the retrospe...
Have you adopted the use of low dose morphine for treatment of cough in patients with IPF?
Yes, I selectively use low-dose morphine for the treatment of chronic cough (lasting more than 8 weeks) in certain patients with idiopathic pulmonary fibrosis (IPF).This includes individuals who demonstrate somewhat preserved lung function (specifically, a forced vital capacity [FVC] of 45% or more ...
What aspects on history and physical exam could help differentiate genetic muscular dystrophy from immune-mediated myopathy?
Great question, and one that comes up all the time in clinical practice. Unfortunately, the question gets a little bit complicated because of the heterogeneity of the musculodystrophies, metabolic myopathies, and neuropathies that can mimic myositis (not to mention the phenotypic variation between t...
How do you determine duration of therapy for patients who have responded well to voclosporin therapy?
Determining the duration of therapy for patients who have responded well to voclosporin therapy in lupus nephritis involves several considerations, including patient-specific factors, disease activity, and risk of relapse. Here is a suggested approach:The duration of therapy is determined by the ren...
How do you manage the wide array of emotions like anger and disappointment patients may have when they first learn of an incurable relapse of an early stage cancer?
This is a really tough question and there is no easy or straight-forward answer. When I consider situations like this, however, I try to follow these guidelines: I use initial diagnostic uncertainty to my advantage. A diagnosis of relapse is almost never made instantaneously (a suspicious lesion on...