Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you combine methotrexate and leflunomide for the treatment of RA?
Absolutely! What a coincidence, as I was just communicating by email with a patient with horrible hard-to-control psoriatic arthritis (PsA) who failed numerous combos and biologics. (I know this question is RA, but also think of LEF with PsA). It was not until I added leflunomide (LEF) to her regime...
Is your decision to prescribe empagliflozin for CKD patients without albuminuria influenced by a recent cost-utility analysis showing that empagliflozin was not cost-effective for this group?
I have not been a proponent of using SGLT2 for patients who do not have proteinuria to begin with. I don't think these patients would benefit much, just as the data for ACE/ARB in these groups of patients is not great. Usually, they progress fairly slowly anyway.
Do you recommend patients with chronic kidney disease avoid supplements containing creatine?
I do not have patients necessarily avoid these supplements. I do advise with supplements in general we don't always know what else is in the supplement and how supplements interact with each other and prescribed medications.
What is your approach to establishing a dry weight in a pregnant patient with ESKD on hemodialysis given the expectation of weight increase and pregnancy-related edema?
I think there is a lot of nuance managing weight in pregnant patients with ESRD. Pregnant patients have better fetal and maternal outcomes when clearance is increased. Outcomes are best with >36 hours of dialysis per week. Adjustment of dry weight should include assessment of volume status, blood pr...
When transitioning from anabolic agent to denosumab, do you stop teriparatide 1 day prior to transition and romosozumab 1 month prior to transition?
I do not believe there is any comparison data to guide this question. My philosophy was to get denosumab going asap at the end of our scheduled anabolic course. I would often schedule a tptd or abaloparatide patient at 23 months to discuss denosumab and get the process started for approval. We often...
What range of musculoskeletal complaints have you seen with romosozumab use?
The most common side effect with Romo is injection site reactions. Some patients may have musculoskeletal pain but so do many patients not on Romo. Overall, I found that it is very well tolerated, but if a patient believes that it is causing major undesirable effects, then it is probably best to sto...
How do you approach immunosuppression in patients with a positive Interferon Gamma Release Assay and prior intravesicular BCG treatment for bladder cancer?
Bacillus Calmette–Guérin (BCG) is the most widely used vaccine worldwide and has been used to prevent tuberculosis for a century. BCG also stimulates an anti-tumor immune response, which urologists have harnessed for the treatment of non-muscle-invasive bladder cancer. As rheumatologists, we occasio...
What dosing range of oral minoxidil do you prescribe for patients with hair loss?
I have really enjoyed adding this to our AGA treatment algorithm. I like to start at half of the 2.5 mg tab for women daily and the full tab for men. I then increase at each follow-up based on the patient's tolerance for AEs (increased hair elsewhere, BP, edema, lightheadedness). I max out at 5 in w...
What’s your approach to recurrent “idiopathic” Erythema Nodosum that failed NSAIDs?
Next step in treatment would be SSKI with gradual dose titration upward to improve tolerance. For recurrent cases of EN, perform pharyngeal culture to look for strep.
How do you determine when to transition off pegloticase to other uric acid lowering therapies?
When to transition patients off of pegloticase is a question that is frequently posed to me by my colleagues and by my patients. Pegloticase is not a drug meant for long-term therapy but rather to achieve specific targeted clinical outcomes. I usually recommend once those outcomes are achieved, that...