Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should patients receive thrombophilia testing in the setting of a provoked VTE secondary to hormonal therapy/OCPs?
Given that oral contraceptives are considered a provoking event (Ortel et al., PMID 33007077), ASH Choosing Wisely guidelines recommend against thrombophilia testing since the recommended duration of anticoagulation is only 3 months. (Hicks et al., PMID 24307720 & Hicks et al., PMID 25472968).
Is there a role for regular hepatitis and TB screening in patients on chronic immunosuppressive therapy in the absence of new risk factors or exposures?
Unless there has been an interval introduction of new risk factor for TB or hepatitis B, there is no need to screen annually and baseline testing is adequate.
Would you consider using teriparatide beyond a cumulative maximum of two years now that the black box warning regarding osteosarcoma has been removed?
This is a very good question. Early studies with PTH compounds for osteoporosis showed you could give it for three years and still have an effect on increasing bone mass. The black box warning was for osteosarcomas that occur in young adults and children, and the black box warning was also for indiv...
Would you consider tamoxifen to be contraindicated for chemoprevention in patients with a history of OCP induced VTE?
Absolutely, yes. SERMs are contraindicated in women who have a history of thrombosis and in women who are pregnant, planning to become pregnant, or are breastfeeding. SERMs are also relatively contraindicated in patients with increased risk of thrombosis, such as those who smoke or have a familial p...
Would you ever consider prophylactic anticoagulation in patients with CKD requiring ESA therapy?
I would not start anticoagulation in this setting solely because the patient is to receive ESA treatment, but would advocate for adjusting the ESA dose to maintain a hemoglobin of 9-10 g/dL, since a number of studies suggest that targeting higher hemoglobin levels is associated with increased risk o...
How do you approach immunosuppression targeting skin thickening in scleroderma after the initial three years of onset?
I think there is still a role for trial of immunosuppression in the case of a patient who has diffuse skin disease and has signs of progression or lack of improvement even if it is beyond 3 years. If a patient has limited skin distribution (i.e., only sclerodactyly) or the skin has not changed over ...
How do you counsel patients on JAK inhibitors about the risk of venous thromboembolism, MACE, and cancer?
I advise patients that there remain many unanswered questions regarding these side effects that will be resolved with longer term use with these agents. Shared decision-making is critical for these discussions. Data available from current extensions of clinical trials for JAKi, additional risk facto...
What is your approach to a patient with an isolated positive rheumatoid factor, negative anti-CCP antibody, and no clinical or imaging evidence of rheumatoid arthritis?
In our clinic, we screen for hepatitis C infection in all patients with polyarthralgias especially if the RA factor is positive. A positive RA factor is non-specific and can be present in a number of chronic inflammatory conditions, autoimmune and otherwise, including alcoholic liver cirrhosis, hepa...
Would you recommend aspirin 600 mg daily for two years to a patient with Lynch syndrome and a history of colon cancer based on the results of the CAPP2 study for cancer prevention?
Yes, I would recommend this, with some caveats/considerations. 600 mg of aspirin daily x 2 years was the dose/duration shown to be effective in CAPP2--recently updated outcomes data from this trial (Lancet 2020) demonstrated an IRR of 0·50 (0·31–0·82; p=0·0057) for CRC among participants who were ab...
In a patient with breakthrough VTE on rivaroxaban, would you switch to apixaban or an agent with a different mechanism of action?
A complex situation and a lot will depend on the clinical circumstances e.g., compliance, type of failure, etc. I would still consider apixaban. However, if the failure was a more serious event, consider alternative anticoagulants.