Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your threshold for number of alcoholic drinks per week before reconsidering prescribing methotrexate/leflunomide?
It's a great question, and the usual practice probably depends heavily on the culture in which one trained/practices. For example, the US and UK governmental guidance are notably different in their recommendations. This contrast in attitudes is also reflected in differences in the governmental defin...
How do you approach contraception and pregnancy counseling in women of childbearing age with Desmoid tumors who may be contemplating future pregnancy?
Sporadic desmoid tumors have a propensity (80% of cases) for women of childbearing age and they do seem to come up during and after pregnancy. Here are my thoughts on contraception and pregnancy for women with desmoid tumors.1. Norethindrone pill. This is not specific to people with desmoids. I am a...
Do you routinely check platelet counts after COVID-19 vaccines in patients with chronic ITP?
Yes. the side effects of COVID vaccines are still evolving. Mild to moderate thrombocytopenia was noted and severe thrombocytopenia is extremely rare. I would follow an abundance of caution and do weekly complete blood counts, especially in the ITP patient.
Is there a role for prednisolone over prednisone in rheumatic patients with hepatic impairment?
Yes. In general, prednisolone is preferred over prednisone in patients with significant liver disease as conversion of prednisone to its active form (prednisolone) may be impaired. The first citation below provides a great deal of information regarding the different steroid formulations.As an aside,...
How would you advise patients with known stable autoimmune thrombocytopenia regarding the Ad26.COV2.S (Johnson & Johnson/Janssen) vaccine?
For patients with autoimmune thrombocytopenia due to SLE, I favor avoiding vaccines that employ a viral vector due to concerns for viral induced lupus flare.For patients with thrombocytopenia in association with antiphospholipid antibodies, would avoid the Johnson & Johnson (as well as Astra-Zeneca)...
Do you routinely prescribe vaginal estrogen therapy post chemo/XRT for female patients finishing anal cancer treatment?
No. We encourage all female patients to use a vaginal dilator and Replens over the counter vaginal moisturizer (vitamin E, B, non-hormonal) after chemoradiation. We also encourage patients to see their gynecologist to discuss topical estrogen therapy. There are potential side effects/drug interacti...
How do you approach the use of low-dose aspirin for primary prevention in non-pregnant patients with SLE and positive aPL antibodies, without clinical criteria for APS?
I personally do not put all asymptomatic SLE patients with aPL labs on low dose aspirin. This is a somewhat controversial topic. Most of the data we have are from observational studies and results are mixed in regards to efficacy of low dose aspirin for primary prevention in this population. SLE pat...
How do you manage testosterone replacement therapy-induced erythrocytosis?
Testosterone is a known risk for thromboembolism. What is not known is whether it is the hematocrit or the testosterone itself that is the trigger for thrombosis. Note also that epidemiologically, the age group that generally is prescribed testosterone also has a high prevalence of thrombosis. My ap...
What do you routinely recommend for non-pharmacologic management of essential tremor?
Similar to above, I introduce the essentialtremor.org website, pull it up in clinic if I have time, and review the assistive devices tab (hand printouts to patients not internet savvy) which I have found very helpful. I have also found some useful wrist weights on amazon. The Cala Trio device is ty...
Do you treat fibromyalgia in your practice or do you refer back to PCP after ruling out autoimmune inflammatory pathology?
The problem of managing fibromyalgia has been the topic of numerous Rheumatology National meetings and more after-hours clinic gatherings. The reality centers around your desire to take care of people; clearly, this is a group of patients who need someone to provide care. Rheumatologists are exceedi...