Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How important do you feel HLAB51 testing is in diagnosing Behcet's disease?
The diagnosis of Behcet syndrome is based on clinical signs and symptoms. Laboratory testing and imaging studies are usually used to rule out conditions that may mimic Behcet rather than confirm the diagnosis. There is a strong genetic association between HLA-B51 and Behcet. About 50–80% of Behcet p...
What is your first treatment of choice in patients with dermatomyositis sine myositis?
Great question! For better or worse, there isn't a great one-size-fits-all answer since choosing the "best" agent means assessing the severity of the disease, assessing if there are extracutaneous manifestations that also need to be addressed (e.g., interstitial lung disease? inflammatory arthritis?...
How do you transition to an anabolic agent in a patient who develops an atypical fracture while on denosumab?
It is not usual to suffer an atypical fracture of the femur from denosumab, however, they do occur. It is useful to start an anabolic agent, either abaloparatide or teriparatide for both augment fracture healing and to treat the osteoporosis. Both abaloparatide and teriparatide stimulate bone format...
How do you manage osteopenia, osteoporosis and calcium / Vit D supplementation in a patient with calcinosis?
Calcinosis is mineralization of the blood vessels. Currently, there is no evidence to support any association with circulating calcium levels and calcinosis. Therefore, calcium and vitamin D supplementation at recommended levels for age will not increase calcinosis. Also, remember that ASCVD, renal ...
Do you avoid intra-articular and bursa/tendon sheath corticosteroid injections in patients with a history of avascular necrosis?
I would give intra-articular or bursa injections of steroids/glucocorticoids in patients with either active ON or a history of GC induced ON. I do not believe the local injection will increase the risk of progression or incident ON, as long as it is not given more often than every 3-4 months.
Should the age at which patients transition from pediatric to adult care differ depending on the disease diagnosis?
First, a distinction needs to be made between transition (which is a long-term, ongoing process) and transfer of care (which is the act of going to one provider to another). Transition introduction should start early, with recommendations that age 12 is a good beginning to introduce the concepts of ...
How do you counsel patients about the risk of osteonecrosis of the jaw with anabolic agents such as teriparatide or romosozumab ?
Drug-induced osteonecrosis of the jaw (ONJ) has been reported to occur with all anti-resorptive osteoporosis medications. Romosozumab has a dual mechanism of actions with both anabolic (bone building) and anti-resorptive effects. In a double-blind, placebo-controlled study involving 3321 subjects wh...
How would you manage a patient with morbid obesity who presents with new symptomatic pulmonary embolism a few days after he was started on DOAC for DVT?
There are guidelines from the American Society of Hematology and The International Society of Hemostasis and Thrombosis as well as expert opinions recommending either apixaban or rivaroxaban for venous thromboembolism or pulmonary embolism in patients with BMI >40. In addition, this includes use as ...
Do you use amyloid lowering therapy in patients on chronic anticoagulation?
I wouldn’t feel comfortable doing this because of the elevated risk of ARIA-H. The Alzheimer’s Association Therapeutics Work Group advised that patients receiving anticoagulants should not be offered lecanemab (Cummings et al., PMID 37357276).
For patient with polycystic kidney disease and proteinuria who are on maximum dose of ACEi/ARB, what are other anti-proteinuric medications that should be considered?
This is a great question because it highlights that patients with ADPKD should have proteinuria worked up as with any other patient with CKD - sometimes even by biopsy if needed (if tissue can be obtained safely, usually requiring urology and possibly using laparoscopic approach if ultrasound is not...