Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients who ask you about trying oral or topical formulations of medical marijuana for pain related to arthritis or fibromyalgia?
Despite the acknowledged widespread use of cannabis in rheumatology patients, there has been no evidence of its efficacy. A recent systematic review of randomized controlled trials found no evidence for the use of cannabinoids, cannabis, and cannabis-based medications in chronic pain management (Fis...
How would you manage a patient with profound dyspareunia after pelvic radiation for anal cancer?
Thanks for bringing up this important topic that remains understudied, with historically widely underestimated incidences of post-radiotherapy dyspareunia. There is currently no standardized method or schedule for assessing post-treatment sexual dysfunction including vaginal stenosis and fibrosis (a...
What baseline work-up do you do for patients with suspected palindromic rheumatism?
I'm sure this varies a lot by rheumatologists. For someone with a pattern of recurrent and episodic arthritis that sounds inflammatory, I think the differential diagnosis should include rheumatoid arthritis, gout, and calcium pyrophosphate deposition disease, polymyalgia rheumatica, and perhaps some...
How do you manage severe vaginal dryness and vulvodynia refractory to topical lubricants in patients with Sjogren's syndrome?
Exclude candida, vestibular gland blockage, and lichen sclerosis.First-line treatment option is vaginal estrogens (cream, ring) or low-dose systemic estrogen (tablet, patch).Second-line options include vaginal DHEA or vaginal testosterone.The severe vaginal dryness in Sjogren's is associated with ly...
How do you approach the pharmacologic management of cancer-related fatigue?
After the above considerations mentioned in the question, management considerations regarding cancer-related fatigue depend on the stage of disease (advanced/metastatic disease vs not) and whether the patient is on active cancer therapy. For both groups, non-pharmacologic interventions have the high...
Is there a role for tocilizumab in treatment of polymyalgia rheumatica in patients who do not have features of giant cell arteritis or rheumatoid arthritis?
In select PMR patients with multiple relapses as corticosteroids are tapered or who have significant steroid toxicity, additional "steroid-sparing" agents may be considered. I do think in this setting tocilizumab may be useful. IL-6 has long been appreciated as a pivotal cytokine in PMR. Two studies...
Does serologic activity (e.g., high titer dsDNA, low complements) without clinical disease activity in a pregnant lupus patient affect maternal or fetal outcomes?
Not specifically. High titers of anti-dsDNA and low C3 and/or low C4, especially those that are adversely trending, are predictors of renal involvement which could adversely affect outcomes especially if the renal involvement mandates a change in therapy, but otherwise no. If these biomarkers are ab...
Are subcutaneous RA therapies less effective in obese patients?
Subcutaneous therapies may be less effective for RA in obese patients in some cases. The literature is mixed: no effect with subcutaneous abatacept but worse response in people with higher BMI with subcutaneous methotrexate.From personal experience, some obese patients or men with higher body weight...
Would you consider an osteoporosis medication in a pre-menopausal/young patient with a low Z score and an ongoing risk factor for secondary osteoporosis such as chronic antiepileptic treatment?
Osteoporosis prevention is always difficult in young patients with risk factors. For young premenopausal women or men below 40, I extrapolate from glucocorticoid-induced osteoporosis (GIOP) guidelines. If Z scores are below -3 and/or there is a history of fragility fracture(s), then treatment with O...
Is romosozumab an option in a patient who has completed 2 years of teriparatide therapy and has a fracture while on denosumab?
Romosozumab would be an excellent option in this setting. Although both teriparatide and romosozumab are anabolic agents, they have different MOAs and there is no cumulative time limit of therapy as there would be in the case of additional therapy with abaloparatide. At the completion of therapy wit...