Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Can Trental + Vit E for treatment of fibrosis be used in patients taking anticoagulants?
Vitamin E can definitely increase bleeding and should not be prescribed by a radiation oncologist for a patient on anti-coagulation. However, bleeding is not a commonly reported side effect of Trental. (Though bleeding does make the extensive list of possible complications.) It inhibits phosphodiest...
What is your approach to long-Covid/post-Covid syndrome in your practice?
Many academic medical centers, including ours, have opened post-COVID clinics, and they are not necessarily managed by rheumatologists nor perhaps they should be. I agree that the symptoms are quite similar to fibromyalgia although, true post-COVID-19 medical problems may well be inflammatory, and f...
Is there a role for starting an anabolic agent in a patient that developed an atypical femoral fracture while on denosumab sooner than 6 months after the last denosumab dose?
The biology of an AFF is still being elucidated. However, there are many aspects of an AFF that are similar to a "stress fracture" in that there is a combination of osteoid and cartilage that does not fully mineralize. Fracture healing goes through a cartilaginous phase, followed by mineralization w...
With what agents can you replace PPIs if they cause thrombocytopenia?
The incidence of PPI-induced thrombocytopenia is very low - and really only reported in case reports. I would suggest ensuring the low platelet count is really from the PPI (in some cases may be reasonable to re-challenge the patient), and not from a more common reason. In a recent case report on La...
Under what circumstances would you consider anticoagulation in a young female patient with persistently elevated factor XI activity?
First, get a baseline D-dimer to see how procoagulant she is at that point. If elevated, long travel on plane, pre-op and post-op for 2 months - consider short-term anticoagulation. If past thrombosis - give lifelong anticoagulation. If pregnant - follow D-dimer; if it goes up, anticoagulate.
Should patients with active multiple myeloma and other gammopathies be routinely vaccinated against herpes zoster?
All patients starting anti myeloma therapy should be on acyclovir prophylaxis, typically starting at 400 mg BID but renally adjusted to 400 mg daily if needed. This provides substantial protection against zoster. Patients may get shingrix but given that their immune response to the vaccine may be su...
How often should you repeat iron testing in patients with hemochromatosis, not on phlebotomy?
I can't think of a reason in the world to not do phlebotomy either therapeutically or through donation until TSAT is around 30 and ferritin is <100. I try to keep my hemochromatosis patients low, not high normal because the propensity for high TSATs makes subclinical deposition easy. I don't think t...
Is it ever reasonable to switch to a different TNFi as opposed to switching to an agent in a different class in a case of TNFi induced lupus or psoriasis?
This is a very interesting question where the answer continues to evolve. I would also like to answer the question separately. Both Psoriatic skin lesions and lupus or lupus-like conditions can be induced by anti-TNF-alpha therapy. The pathogenesis may involve changes in cytokine balance.Regarding P...
How long would you treat with antimycobacterials before starting biologic DMARD in a patient with latent TB and active rheumatoid arthritis?
This is a common question rheumatologists ask their ID colleagues. Given the diversity of patient presentations, though, there isn't a blanket answer. One reason there's no blanket answer is because it is so hard to study LTBI risks, due to infrequent conversion to active TB, which is a fortunate th...
How do you approach management of sickle cell patients who mistrust Western medicine and prefer naturopathic therapies?
With compassion and understanding, I would explain that the lifespan of patients with SCD in regions with access to Western medicine far exceeds that where the disease is most prevalent. Controlled clinical trials have proven the utility of hydroxyurea to alter beneficially the course of disease and...