Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What recommendations do you provide to patients who develop ocular side effects with Dupixent?
I would start with over-the-counter artificial tears without preservative and then refer to an ophthalmologist, ideally a corneal specialist who is experienced in the nuances of treating this condition. I have also had success switching from Dupixent to Adbry, although JAK inhibitors are a better o...
What prescription or over-the-counter therapies have you found effective for helping vitiligo patients cover active areas?
As Dr. @Dr. First Last mentioned, selecting the correct topical steroid strength based on location is important. We have had patients make great progress (even without nbUVB therapy / xTrac) by alternating every 1-2 weeks with a topical steroid and a non-steroidal (i.e., Pimecrolimus cream or Tacrol...
How do you approach tapering off JAK inhibitors in patients with rheumatoid arthritis who are in sustained remission?
My approach to treatment changes for RA patients who are in remission is usually not specific to the kind of medications they are on. Unless the patient has adverse events, I tend to continue the medication or combination of medications that got them into remission. As we know, RA is a chronic condi...
How do you approach methotrexate management in patients with rheumatoid arthritis and moderate NASH but no fibrosis per FibroSURE?
In this scenario of a patient with defined NASH by Fibrosure or alternative biomarker or predictive index of fibrosis, I would refer for baseline Fibroscan (transient elastography) to determine the degree of steatosis and presence/degree of fibrosis. NAFLD is common in our population with an estimat...
Is there a role for low dose aspirin in a patient with AVN in four large joints who has underlying well-controlled SLE and positive APLs but no history of clots?
AVN in SLE patients is common, most often in the context of glucocorticoid use. Thus, in this case, there is no evidence that APLAs are the etiology. Moreover, to the best of my knowledge, there is no evidence that primary prevention with aspirin in the setting of APLAs is effective. So I would not ...
What is your approach to discussing risk of adverse cardiovascular events in patients with RA whom you are considering starting a JAK inhibitor?
I would refer to the recommendations in the January 28, 2022, position statement by the American College of Rheumatology. This statement emphasizes the importance of shared decision making between the rheumatologist and the patient. There are many options available to treat RA that do not have a sim...
How does failure to recover clinically after >2 years in a patient with suspected diabetic amytrophy shift diagnostic and therpeutic approach?
The natural history of diabetic amyotrophy is to improve after deficits have reached a nadir; the improvement can be incomplete, but usually occurs within 12-18 months from the onset of symptoms. Therefore, if there are persistent but stable deficits 2 years after the onset of symptoms this may repr...
Are there any concerns utilizing apremilast for psoriatic arthritis in patients who are also taking roflumilast for COPD?
This is an interesting question which I don't have a good answer for. In my experience, I have not used the combination and upon my review of the literature, I did not find any reported use of the combination. Roflumilast is currently being studied in and shows efficacy in psoriasis both in topical ...
Do you stop hydroxyurea or switch to an alternative therapy in a male patient with controlled Hb SC disease who is interested in having children?
Part of the reason the patient may have controlled disease could be the hydroxyurea and so stopping that therapy might not be best for the patient's disease. Also, many patients on hydroxyurea can still get their partner pregnant. So, I would only consider stopping/holding it if the patient is havin...
Have you had success using resorcinol 15% topically for limited hidradenitis?
I have compounded 15% resorcinol cream for my HS patients to apply daily to affected areas and to apply BID when flaring. I have a small number but they have reported good success.