Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you check pertussis serologies when sending labs for antiphospholipid syndrome?
The short answer is no. I do not check pertussis antibodies when evaluating patients for anti-phospholipid syndrome. A slightly longer answer is still no and, for example, a review published in the Annals of Rheumatic Diseases by Ron Asherson in 2003 discussing the relationship between various infec...
In patients with a history of HIT, how do you counsel them on the use of the AstraZeneca vaccine given reports of unusual thrombosis and association with PF4/heparin antibodies?
Until we know more, it seems prudent to avoid the AstraZeneca and J&J vaccines, particularly if there is a history of HIT. The Pfizer and Moderna vaccines use a different technology and have not been associated with the thrombosis/thrombocytopenia syndrome.
How do you advise patients who had autoimmune diseases "triggered" by COVID infections on getting COVID vaccination?
To date, it is unclear whether there is a causal link between COVID-19 and incident autoimmune disease at a rate higher than the incidence of autoimmune diseases in the general population, although, there are several case reports and case series describing new cases of autoimmune disease that began ...
What is your approach to managing abnormal lipids in a patient on tocilizumab?
This discussion would apply to treating rheumatoid arthritis with tocilizumab: A baseline lipid panel is standard of care to be drawn prior to initiation of tocilizumab therapy. If the baseline lipid panel (before therapy) were abnormal, I would initiate a discussion about changes in diet and the po...
What additional testing, if any, should be performed for an adolescent patient with heavy menstrual bleeding and a negative von Willebrand disease evaluation?
I presume that the adolescent with heavy menstrual bleeding whose von Willebrand panel is negative has already had a CBC and baseline coagulation screen (prothrombin time, activated partial thromboplastin time, and fibrinogen or thrombin time) performed. If that is the case, I would suggest evaluati...
Do you approach therapy differently for patients with a diagnosis of osteoporosis based on a fragility fracture rather than based on bone mineral density on DXA (assuming no secondary causes of osteoporosis)?
This is an interesting question but the question does not define the bone density results in the individual(s) in question with a history of a fragility fracture. There are people who sustain such fractures with normal bone densities and of course, many individuals sustain fragility fractures with l...
Do you eventually stop urate-lowering therapy in gout patients with CKD who start hemodialysis?
Hemodialysis is an extremely effective serum urate lowering therapy (ULT). As such, whether or not to keep patients on other ULT depends on average serum uric acid levels, how often a patient is having flares, etc. From what I have seen, although some patients will have increased flares in the first...
What abortive migraine treatment is preferred in pregnant patients?
Sumatriptan has a good safety record in pregnancy based on pregnancy registries and studies.
Would you recommend a CGRP inhibitor for migraine prevention in pregnant patients?
No, I would never recommend the use of a CGRP inhibitor during pregnancy (or for a woman breastfeeding for the matter). Currently, there exist five anti-CGRP preventative options with a sixth most likely to be FDA approved here shortly. Of the five currently approved CGRP inhibitors for migraine pre...
At what point could starting AEDs be considered for patients with recurrent simple febrile seizures?
Assuming this is a young child, it is a subtype of "provoked" seizures. It is reasonable to treat if they are frequent or severe. Any ASM will do. Wean off like any other ASM treatment: slowly and gradually. Febrile seizures should not occur after the age of 5 or so.