Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you follow patients with elevated ESR/CRP if their work-up for rheumatologic etiology is unrevealing and no other cause is identified?
The short answer is yes for most cases. That said, there are many variables. Typically, elevations in acute phase reactants (ARPs) occur in response to different initiating events and can be observed to resolve on repeat testing. Persistent elevations in ARPs in the absence of clinical signs and sym...
What are the most effective therapies for CPPD with a "pseudo-RA" pattern?
That is a great question! The short answer is that we really don't know. There are no good quality RCTs for CPPD. In my experience, these patients are quite difficult to manage. I will often start with low dose prednisone (which almost always works) and then search for a steroid-sparing agent. I sta...
Are there any situations you would recommend prophylactic anticoagulation for a patient with Factor V heterozygosity?
In short, no. Thrombotic risk is a complex variable with many contributing components. The presence of a single FVL allele, while it appears to increase the risk somewhat, is not sufficiently predictive of overall risk to provide a basis for administering prophylactic anticoagulation in a clinical s...
What is your approach to gynecologic examinations/surveillance in a standard risk patient on adjuvant tamoxifen?
In the absence of symptoms (abnormal bleeding or discharge, pain, etc.), I do not recommend gynecologic examinations/surveillance beyond what is appropriate given the woman's age. First, premenopausal women on tamoxifen are not at increased risk of developing endometrial cancer. In postmenopausal wo...
Should tuberculosis screening be performed before beginning methotrexate for treatment of rheumatoid arthritis?
While it is not recommended or required to screen for latent TB (LTBI) prior to starting methotrexate, for many patients this may serve as a good opportunity to screen for LTBI, as many patients will go on to require biologic therapy due to incomplete response to methotrexate. There are many limitat...
How do you manage post-menopausal osteoporosis in a patient with stable bone density and no fractures after three years of holiday after giving zoledronic acid?
If the BMD is stable at three years of a post-treatment holiday, I would simply continue the holiday for another 1-2 years. The majority of post-menopausal women were able to achieve 5 years of treatment holiday before BMD dropped to baseline. Repeat the bone density measurement each year or two and...
Is it ever appropriate to initiate a higher initial dose of allopurinol (such as 300mg daily) than is typically recommended in gout patients at low risk of allopurinol hypersensitivity syndrome and severe hyperuricemia?
Usually, allopurinol is started at a dose lower than that and gradually titrated up. This is the best strategy. In a rare instance, allopurinol may be started at 300 mg initial dose - where the patient has tolerated it at this or higher dose previously and is currently non-adherent; or has severe hy...
What is your approach to a patient with positive antiphospholipid antibodies who otherwise do not meet clinical criteria for APS?
As antiphospholipid antibodies constitute a diagnostic criterion of SLE, such patients may need to be evaluated and monitored long term for both SLE and APS.
What is your approach to monitoring lipids in patients with rheumatic diseases such as RA and SLE and do you have a lower threshold to start lipid lowering agents compared to the general population?
In patients with SLE/RA, there is a higher risk of cardiovascular disease compared to age-matched controls. This is multifactorial from underlying traditional risk factors such as obesity, HTN, DM, HLD, but may also be increased due to side effects of steroids, biologics, and other medications, and ...
How long do you continue steroid-sparing agents such as tocilizumab for GCA once the disease is in remission off steroids?
This is an excellent question and one we confront regularly. This is another of what I call “happy problems” because it is a consequence of increasing options for effective therapy for our patients.Tocilizumab is clearly an effective agent for some patients with giant cell arteritis (GCA), and patie...