Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?
This is an interesting clinical scenario. It highlights some of the current issues we face as rheumatologists, namely an atypical presentation of one of our more common diseases. This patient is labeled as having seropositive rheumatoid arthritis yet lacks arthritis features. I suspect the diagnosis...
Is there a role to continue aspirin in patients with myeloproliferative disorders who have never had a thrombotic event that are starting DOAC for stroke prophylaxis with newly diagnosed atrial fibrillation?
Aside from treating erythromelalgia, transient ischemic attacks (TIA) such as ocular migraine or documented atherosclerotic disease, aspirin has no role in the management of the MPN, despite the widely published recommendations for its use, particularly in so-called "high risk" polycythemia vera (PV...
Would you avoid combining JAK inhibitors with IVIG given the risk of thromboembolism?
The evidence for this is not very clear and limited. I think a honest discussion about the risk of JAKs and IVIG with the patient will be the most important; but as long as there is no clotting history or high risk of DVTs/PEs, and this is documented, and if a patient needs both medications to attai...
When would you treat mild anemia from low testosterone in an older male?
The primary indication for testosterone treatment is symptomatic hypogonadism and not anemia. Given the risk for adverse events in terms of erythrocytosis, cardiovascular events, and potential prostate diseases, the risk of providing testosterone for asymptomatic, mild anemia outweighs its benefits,...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
How do you manage the developmental and behavioral regression seen in Down Syndrome Disintegrative Disorder (DSDD)?
Thank you for this important question. One of the keys is to ensure that the change and regression being seen is DSDD or something else. Sometimes, this is confused with Alzheimer's seen in older individuals with Down syndrome. DSDD is seen in much younger people, late teens, and 20's as a more rapi...
How do you decide between using immediate-release versus long-acting lithium?
In general, long-acting (i.e., controlled release) lithium is thought to cause less nausea and other common side effects (like tremors) than IR formulations but has also been associated with higher rates of diarrhea due to differences in absorption. Another consideration may be the dose you are try...
Should systemic anticoagulation be considered for patients with a less than 1% atrial fibrillation burden on outpatient monitoring with an elevated CHADSVASc score and acceptable bleeding risk?
This is a recurrent question. My policy is to anticoagulate such patients. The cutoff for anticoagulation is still controversial though. I believe that any episodes lasting longer than 5 min deserve anticoagulation. Not so sure what to do with shorter episodes but my philosophy is that prevention of...
How have you incorporated new psoriasis therapies such as deucravacitinib and bimekizumab into your hierarchy of psoriasis treatments?
I have had good success with both deucravacitinib and bimekizumab and these agents are two welcome additions to our psoriasis treatment arsenal. For deucravacitinib, ever since I included it in my list of options in treating psoriasis - as an aside, I used to skip over orals due to lack of efficacy ...
How do you counsel patients on the risks and benefits of an IL-23 agent versus an IL-17A or IL-17A/F agent?
Both IL-17 and IL-23 agents have demonstrated excellent efficacy for psoriasis. Choosing between them often comes down to access and insurance coverage.With that being said, considerations include: Side effect profile: The side effect profile for both IL-23 and IL-17 agents is similar, with the exc...