Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should methotrexate be categorically avoided in RA patients with COPD or RA-ILD?
Thanks for raising a very important question. It is something that every practicing Rheumatologist comes across several times during their career.The traditional teaching has always been to avoid using Methotrexate in patients with underlying pulmonary conditions due to the associated risk of Hypers...
Should MTX be avoided in RA patients with asymptomatic lung nodules?
It is well established that in some RA patients, methotrexate does cause accelerated nodulosis predominantly in the hands which improves after stopping the medication. That does not mean having pulmonary nodules is a contraindication to use methotrexate. I recommend doing frequent chest x-rays for m...
Should methotrexate be stopped prior to radiation therapy if a patient has rheumatoid arthritis?
I have not stopped as dose of MTX for RA is low (7.5 mg) and there is data of CMF with RT for breast cancer with higher dose of MTX showing no significant increase in morbidity.
Do you avoid triptans in patients on SSRI's due to the potential risk of serotonin syndrome?
I feel very comfortable using triptans with SSRIs/SNRIs. In 2010, the American Headache Society released a position statement on this very issue:Evans et al., PMID 20618823Their position is that the available evidence does NOT support the claim that triptans should not be used with SSRIs or SNRIs.A ...
Do you recommend antibiotic prophylaxis for an ESKD patient with a tunneled dialysis catheter who is planned for a dental procedure?
I do not. Which procedures require antibiotic prophylaxis has always been a very confusing issue for me. It also seems to change often. However, with dental procedures, the main organism responsible for bacteremia is streptococcus of viridans group which is an unlikely cause of line infection. I thi...
What is your approach to management of patients with recurrent nephrolithiasis and osteoporosis who are receiving teriparatide?
Bones and calcium containing kidney stones can interact. I find it interesting that patients who have primary hyperparathyroidism are prone to predominantly calcium phosphate kidney stones, since the action of parathyroid hormone on renal tubes is to reabsorb urine calcium. That’s why people with hy...
Do you have recommendations after prostate RT for patients who want to conceive?
This conversation has two directions based on whether or not the patient currently can produce semen. Assuming he currently canNOT produce semen obtained via ejaculation, I would refer him to a urological specialist for surgical extraction of sperm. From that point, the sperm could be inspected by a...
Would you consider prophylactic antifungal treatment prior to immunosuppressive therapies in a patient with previously treated pulmonary coccidiomycosis and residual parenchymal changes?
If the pulmonary coccidiomycosis was treated in the past, I would not necessarily prescribe prophylaxis, but that also depends on the meaning of "residual parenchymal changes.” If you’re referring to post-inflammatory fibrotic changes, then prophylaxis likely is unnecessary. If you’re referring to c...
Would you use sumatriptan in a patient with a history of cerebral aneurysm rupture?
Yes. There is no evidence that the use of triptan in patients with an unruptured cerebral aneurysm, or in those who have a history of ruptured aneurysm that have been coiled or clipped, increases the risk of serious adverse events. I would not use them in the setting of acute subarachnoid hemorrhage...
Do you routinely recommend suppressive antibiotic therapy for patients with spinal hardware infections who have undergone surgical debridement with retention of hardware?
Executive Summary: "State-of-the-Art Review: Diagnosis and Management of Spinal Implant Infections" was published in Clinical Infectious Diseases, December 15, 2024 issue, by Tai and colleagues from the University of Minnesota, Mayo Clinic, Hospital for Special Surgery (New York) and the University ...