Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach management of patients with inflammatory arthritis who are asymptomatic but develop radiographic progression?
Radiographic disease progression remains the gold standard test for assessing disease activity in patients with RA. Therefore, any time one notes progression of radiographic change, this finding needs to be taken seriously. Since plain radiographs may take many months or years to demonstrate such ch...
What kinds of dental work do you particularly worry about and try to avoid in patients on bisphosphonates?
Firstly, the incidence of BRONJ (bisphosphonate-related osteonecrosis of the jaw) is very low with all drugs of this class. However, many patients and dentists are concerned about the possibility of this problem. Generally, BRONJ occurs after an extraction and subsequent poor healing at the extracti...
What indicators do you use to determine whether a patient is having a favorable or unfavorable response to nintedanib?
Unfortunately, there probably isn't a way to do this. It might be helpful to step back and see what nintedanib buys you: as compared to placebo, the nintedanib group suffered less FVC decline by ~110mL/year. Real-world data suggest there's probably a mortality benefit if you have your patients on it...
What is your approach to assessing whether oral/nasal ulcerations are features of systemic lupus erythematosus versus from another etiology?
Mucosal ulcerations due to lupus erythematosus (LE) are more complicated than many of us think. So, this question and answer are not as straightforward as many think. First, the subtitle to this question is misleading. I would not use the word "blister," a lay term that I usually reserve for vesicle...
How do you counsel patients on the benefits of diet and exercise in OA in a way that motivates them to comply?
Although this issue is critically important for the care of patients with knee OA, the question itself is a bit disingenuous, as long-term behavior modification is very difficult to achieve on a population level. There is abundant evidence that exercise and strengthening of the periarticular muscula...
How do you counsel patients who prefer to continue TNFi therapy indefinitely for rheumatoid arthritis despite long-standing remission?
I explain the risk of stopping and having a return of disease after stopping (that this could be a “drug holiday” of limited duration) and that this return of disease activity may not respond to restarting the TNF blockade therapy that had been working well for them. Then they would have to start a ...
Do you recommend Vitamin D and omega 3 fatty acid supplementation for prevention of autoimmune disease?
A resounding "Yes!" but with caveats. I do not recommend them independently but as part of a list of recommendations (listed below).There is mounting data that many autoimmune disorders (especially systemic lupus erythematosus, SLE, and rheumatoid arthritis) probably occur due to environmental (exte...
How would you approach evaluation of a patient with persistent elevated ACE (angiotensin converting enzyme) level without evidence of cutaneous, ocular, or pulmonary granulomatous disease?
An ACE level was previously commonly used in sarcoidosis, often as a diagnostic tool. However, due to its low specificity, it has fallen out of favor. In cases where an ACE is elevated but an evaluation for sarcoidosis has turned up negative, consider other causes for an elevated ACE. Any disease th...
How would you treat a sarcoid patient whose only manifestations are B symptoms and generalized lymphadenopathy?
Historically, the term “B symptoms” was developed to describe poor prognostic signs and symptoms in stratifying patients with lymphoma. Specifically, these were fever, drenching night sweats, and significant weight loss (>10% over six months) and portended worse prognosis. B symptoms, of course, can...
Can Milwaukee shoulder present with a large subacromial bursitis, or does it predominantly cause joint effusion/destruction?
This is an interesting question. Milwaukee shoulder is primarily considered an arthropathy due to basic calcium phosphate crystals (Halverson et al., PMID 2155593). So the effusion will be seen in the joint, but because of secondary damage to the capsule and rotator cuff, it will typically extend in...