Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is it okay to use COX-2 selective NSAIDs in patients with IBD-associated arthritis when the IBD is in remission?
I do not feel comfortable prescribing COX-2 NSAIDS to patients with IBD in remission. If I have such a patient and an NSAID is the major therapeutic option, I will reach out to the treating gastroenterologist for an opinion on whether this is advisable.
Should patients be screened for hepatitis B/C prior to starting a conventional synthetic DMARD such as methotrexate?
If you are even thinking about it, YES!!!!AASLD suggests HBV screening when contemplating immunosuppression with HBsAg, anti-HBcore, and anti-HBs for immunization status (separate issue). HCV-Ab should be done at the same time as I have advocated for many years, but now, the practice is catching up ...
Do you regularly do bone density testing to screen for osteoporosis in men with rheumatoid arthritis without any other risk factors?
An important comorbidity in RA is fragility fractures. These patients are at higher risk of OP because of increased pro-inflammatory cytokines and glucocorticoid treatment. OP screening strategies are both feasible and effective in RA patients and recommended by most specialty organizations. Both me...
In which osteoporosis patients would you consider starting with anabolic therapy over antiresorptive therapy?
Anabolic therapies including teriparatide (PTH-analog), abaloparatide (PTHrP-analog), and romosozumab (anti-sclerostin) are all indicated for patients with osteoporosis and high fracture risk. Although denosumab (anti-RANKL) is an antiresorptive agent, it also leads to significant bone gain similar ...
When treating patients with low bone mineral density, when/how do you monitor bone turnover markers (NTX, CTX, etc)?
It is a bit difficult to answer this question without more information. If you are monitoring a patient during a drug holiday, I would order a CTX-1 and PINP when discontinuing the bisphosphonate and then again after one year. If the levels have increased over 50% from the year before that would tri...
Is there a role for ultrasound in assessing for "clinically silent" inflammatory arthritis prior to tapering DMARD therapy?
This is an excellent question. Data have been mixed with regards to the significance of sonographic synovitis (grayscale or Doppler) in "clinically silent" patients on immunosuppression. Initially, the question was asked in earlier papers whether such patients warrant an INCREASE in their immunosupp...
What agent would you choose for a patient who needs osteoporosis therapy after a bisphosphonate holiday?
This is a question of high clinical importance but with a lack of good controlled data. First and foremost, a holiday should be viewed as a temporary discontinuation of therapy. Anecdotally, I would say about 30% of my patients need to go back on therapy. There is a lack of data to support clinical ...
In patients with knee osteoarthritis, do you recommend the use of hyaluronate injections if it is available and affordable for the patient?
This is a very controversial topic because the data simply hasn't been convincing. Many professional medical societies have either rejected HA or recommended it conditionally (or recommended against it conditionally). That being said, the literature has plenty of case series and reports of great rel...
Do you use hydroxychloroquine for prevention of neonatal lupus in patients with a positive SSA who are planning on becoming pregnant?
There is some evidence that hydroxychloroquine can prevent CHB in patients at high risk (mothers who already had a fetus with CHB in a previous pregnancy (Izmirly et al., PMID 32674792). There is scant evidence about neonatal lupus and the use of HCQ to prevent it. HCQ is generally well-tolerated an...
Is chronic major salivary gland enlargement in a patient with Sjogren's an indication for immune-modulating therapy such as hydroxychloroquine or methotrexate?
Although there have been 2 patients reported to have an improvement in parotid size with hydroxychloroquine and methotrexate are generally ineffective for the treatment of chronic bilateral major salivary gland enlargement in Sjogren's. For acute bilateral swelling, a tapering dose of prednisone can...