Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How often should lupus anticoagulant be checked in patients with SLE if prior was negative or if prior was positive?
The key question when considering retesting for any laboratory test, including antiphospholipid antibodies (aPL), is: How would a positive or negative result change the patient's management or prognosis? This question helps guide the decision-making process by focusing on the potential clinical impl...
Is narrow-band ultraviolet B (nbUVB) phototherapy contraindicated or recommended with caution in patients with a personal history of melanoma?
Although it is challenging to be definitive, our current literature suggests that nbUVB does not increase the risk of melanoma or nonmelanoma skin cancer.Previous studies suggesting a possible increased risk with nbUVB included patients with a history of PUVA, which has been shown to increase risk. ...
How do you approach RA management in a patient who develops a new solid tumor while on therapy?
Risk-benefit ratios need to be individually assessed. There are several aspects to take into account: Choice of DMARD - Data on impact of various DMARDS on cancer recurrence or progression is scarce, especially for patients with active cancer. In general, there are few concerns for conventional DMA...
Which medications do you deem necessary to stop prior to measuring plasma renin and plasma aldosterone when evaluating a patient for possible primary aldosteronism?
The most important medications to stop before checking renin and aldo levels are spironolactone, amiloride, triamterene, finerenone, and eplerenone. Ideally, patients should be off these meds for at least 6 weeks before testing. A pathologic primary aldo can be detected while taking beta blockers or...
How do you approach prevention of kidney stones in patients with an ileal diversion and recurrent nephrolithiasis?
My first step, is to perform a kidney stone analysis. Kidney stones are not a "monolithic" disorder; rather they are "symptoms" of a diverse group of renal mineral metabolism and acid-base disorders. my next step in this case would be to obtain a 24-hour urine supersaturation study. I would be parti...
How do you approach treatment of a patient with active RA and a history of Lynch Syndrome?
The presence of hereditary polyposis coli and its predisposition to colon cancer should have little effect on the management of RA. Available data indicate that methotrexate has at best a neutral effect on predisposition to malignancy. There are data to suggest that the combination of methotrexate a...
Do you discontinue IL-17A, IL-17A/F, or IL-23 blockade in pregnant patients with psoriasis?
I always give my patients the option of discontinuing but put it in perspective. For the most part, my patients do end up stopping, with the plan to restart after delivery. We discuss a few topics: Pregnancy doesn't tend to worsen psoriasis in general, in fact in many patients, it gets better. It i...
How often would you perform an upper endoscopy on an individual with chronic gastritis and previously eradicated H pylori with respect to risk of gastric malignancy?
Endoscopic surveillance of patients with chronic gastritis and previously eradicated Helicobacter pylori (H. pylori) would primarily hinge on endoscopic/histologic features on index endoscopy.Endoscopically and histologically, the presence and extent/distribution of gastric pre-neoplastic lesions no...
Do you recommend genetic screening for FMF in asymptomatic first-degree relatives with a strong family history (multiple family members, severe/refractory disease)?
In the absence of FMF symptoms, it is not necessary to obtain genetics in first-degree relatives of patients with FMF. More critical than genetics is to screen for systemic inflammation and amyloidosis, which I would consider doing. I would check inflammatory markers and urinalysis with urine protei...
What is your approach to maintenance of sotalol in terms of drug monitoring and duration of therapy for outpatients who remain in normal sinus rhythm?
I have a healthy respect for the proarrhythmic potential of sotalol. I routinely load and increase the dose in the hospital setting. Not too dissimilar to dofetilide. I avoid as much as possible other drugs that prolong the QT interval and I use caution with other drugs that slow the HR. I monitor E...