Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to treating tophaceous gout in patients whose uric acid is below 5 prior to initiating uric acid lowering therapy?
The finding of tophi is associated with elevated total body uric acid. If this is a true serum uric acid, it is conceivable the patient is a high urine excretor to explain the low serum uric acid. Checking uric acid excretion could elucidate this. Alternatively, low serum uric acid level could be a ...
How do you counsel patients on driving who have PNEA?
No law or rule here, so case by case and good old clinical judgment. Event severity, type, frequency, etc.A couple of references:Asadi-Pooya, et al., PMID 32913946Benbadis et al., PMID 10897163
With the increasing reports of correlation of frontal fibrosing alopecia and titanium dioxide sunscreens, do you advise patients against the use of micronized sunscreens on the face?
Yes, I believe titanium nanoparticles can be a trigger, and I advise avoiding this ingredient in sunscreens and foundations.
What is your experience with using extended release intra-articular steroid preparations, such as Zilretta in patients with osteoarthritis?
Intra-articular glucocorticoids have been used for decades to treat painful knee osteoarthritis. In the past, steroid preparations of relatively insoluble crystals such as triamcinolone hexacetonide were used with the intention of prolonging the duration of intraarticular action. Although the retent...
Do you measure testosterone in men who will be receiving ADT?
I do check before starting ADT. I make sure to check after ADT completion as well. A post-treatment low PSA level in the setting of a low testosterone has a different meaning than a low PSA in the setting of a recovered testosterone. It also gives you a potential explanation for a slight temporary P...
Would you avoid the entire class of bisphosphonates if a patient develops an allergic reaction, or would you consider the use of an alternative bisphosphonate?
Interesting question and an important clinical issue. If the adverse event or side effect was not serious, I would try another bisphosphonate. If it occurred on alendronate, I would try a low dose or risedronate and monitor. If the side effect occurred from the IV infusion, I also would try a low do...
Does romosozumab need to be followed immediately by an anti-resorptive agent to preserve BMD gains, or could you consider a drug holiday?
A drug holiday after romosozumab is not appropriate, since we know from the phase 2 studies that BMD rapidly declines if it is not followed by antiresorptive therapy. I suggest starting an antiresorptive agent 1 month after the last dose of romosozumab, or soon thereafter. Studies show that Dmab aft...
How do you approach treating necrobiosis lipoidica, especially cases that have ulcerated?
ILK for early lesions, Pentoxyphylline helps with pain, optimize glycemic control, doxycycline, unna boot/wound care.
What is your approach to refractory erosive osteoarthritis?
Indeed, JAKi seem to have a more broadly-acting antiinflammatory/immunosuppressive activity than some of our other DMARDs and biologics particularly. I have had a patient or two with EOA who have failed JAKs, but in almost all of those patients they initially had a good response, just with subsequen...
How do you approach the continued use of TNF inhibitors in a patient with inflammatory arthritis who develops a positive dsDNA without clinical evidence of drug-induced lupus?
This is a good question and more common than we think. Most of us are not routinely drawing dsDNA ab when the patient does not have symptoms; some reviews suggest up to 29% (see review below). I have seen this, however, and continued medication with monitoring (following dsDNA ab levels with C3 and ...