Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
Do you offer iron supplementation to a non-anemic adolescent athlete with a low ferritin?
I prefer having a TSAT on an overnight fast. Extreme athletes have increased hepcidin. If ferritin is greater than 30, my cut-off, no. If TSAT is 19 or less, yes. I would not criticize someone who gave iron, but PO iron is pretty tough to take. I would prefer staying within the current parameters of...
Do you monitor RS3PE patients for GCA with the same vigilance that you do in PMR patients?
I don't think there has ever been a confirmed case of GCA in someone with RS3PE. In this way, RS3PE is more similar to seronegative RA than PMR. However, it is possible that some patients with RS3PE may have overlapping features with cases of PMR, such as describing shoulder and hip girdle stiffness...
What is your first choice contraceptive agent for women with SLE?
In general, I recommend either IUD (progesterone or copper) or nexplanon due to the safety profile as well as efficacy. Progesterone IUDs can be safely used for all lupus patients as well as those with APS. Copper can as well but would use caution in patients with APS on therapeutic anticoagulation ...
Would you consider HRT after BSO in a pre-menopausal gBRCA2+ patient who has no intention of ever having prophylactic bilateral mastectomies and who declines chemoprophylaxis?
Yes, I would consider HRT in this patient with several caveats and realizing that there are no data specifically applicable to this situation. Still, one can make inferences from the existing literature. There are well-documented long-term effects and lower survivals in younger women who have had an...
In what situations do you consider platelet-rich plasma injections in patients with osteoarthritis?
The literature on this topic is sparse, largely confined to discussions of knee OA, and unconvincing of real benefit. I would like to see well-designed clinical trials dedicated to the benefit of PRP in OA. I honestly cannot think of a situation when I would consider PRP injections for osteoarthriti...
Is it safe to use statins in IIM patients if HMGCR antibodies are negative?
Absolutely, yes. Statins are a very important drug for patients with cardiovascular disease and should be given to most patients with myositis except patients with known immune-mediated statin myopathy or HMGCR Positive antibody. I would monitor CK levels before and 3 and 6 months post statin, as we...
How would you manage OCPs in a patient who develops a VTE while on treatment?
If a patient has a venous thromboembolic event, while on a combined estrogen-progesterone oral contraceptive, it is reasonable to continue the OCP with the initiation of anticoagulation. A study from 2016 revealed that it was safe to continue hormone therapy with the anticoagulation (Martinelli et a...
Would a history of definitive chemoRT for anal SCC change the workup for an ASCUS/HPV negative PAP smear in a patient who has never had an abnormal PAP smear in the past?
Interesting question. We do know that radiation changes can lead to atypia which can interfere with cytological analysis. I would counsel the patient that her current ASCUS/HPV negative pap smear results may have some relation to her prior radiation, but ultimately I would still follow ASCCP guideli...