Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to treating premenopausal woman with OI with a new compression fracture?
Young women with idiopathic premenopausal osteoporosis likely have low bone formation. I was not told her BMD but I will assume it is low. An antiresorptive does not make much sense because she is producing enough estrogen to keep her cycles going. There has been some published data with the use o...
How do you approach patients with malignant melanoma who are disease free on immunotherapy for over 3 years?
The prognosis of metastatic melanoma patients treated with immunotherapy has improved considerably. Based on the 6.5-yr update to the CHECKMATE-067 study (presented at ASCO 2021 meeting), the OS for patients treated with ipi/nivo is 49%, 42% for nivo alone, and 23% for ipi alone. If the patient has ...
How do you decide when to try stopping hydroxychloroquine in patients with erosive osteoarthritis?
As we lack any peer-reviewed evidence that hydroxychloroquine (HCQ) effectively and significantly helps with erosive osteoarthritis, I would stop the drug if there was no relief within 2 months (if I had started it for a patient). While HCQ (and other DMARDs) are often used empirically with these er...
How do you approach treatment of PMR in a patient who has had avascular necrosis of the hip after starting steroids?
In this clinical scenario, I strongly advise avoidance of steroids. The data looks promising for using anti-IL-6 therapy in PMR. I don’t think it should be considered first-line therapy for our patients yet but should be reserved for those who have major contraindications or issues regarding the use...
How do you treat a patient with warfarin failure, with therapeutic INR 2-3 at the time of DVT, and no underlying malignancy or hypercoagulable state?
I would give DOACs a shot in this case. The INR of 2-3 at the time of DVT "Diagnosis" might have been <2 at the time of DVT "development/occurrence" depending on how frequently the INR had been checked. I would, of course, maximize risk factors control as well.
For a patient with osteopenia or osteoporosis, how long can intravenous zoledronic acid be maintained if there are not adverse events?
I generally prescribe Zoledronate annually for three years for patients with osteoporosis who are at increased fracture risk. I will occasionally add an additional treatment 18-24 months after the third infusion if there has been a positive response to the original treatment regimen and I feel that ...
How would you manage a patient with recurrent calcium phosphate nephrolithiasis who has hypercalciuria, hypocitraturia, and a urine pH greater than 6.3?
Good question! Calcium phosphate stone formers are the second most common type after calcium oxalate stone formers. The underlying problem is an elevated urine pH. Your differential diagnosis will include primary hyperparathyroidism, renal tubular acidosis, medullary sponge kidneys and the use of al...
How would you approach a woman with APLA but no thrombosis/APLS, a history of ITP without bleeding who is now pregnant?
As a rheumatologist, I would want to make sure this patient does not have SLE. If no suspicion for SLE (and no previous obstetric complications), I would mostly likely monitor closely during pregnancy without any additional interventions.
When would you consider initiation of bempedoic acid for statin intolerant patients (i.e. LDL threshold, comorbidities)?
Monitor bempedoic acic as you would a statin. I will usually check LDL-C response as well as LFTs within 3 months of starting.
When would you consider initiation of low-dose aspirin for primary prevention and/or statin therapy in patients with acceptable bleeding risk and evidence of coronary artery calcification on prior CT chest imaging?
Several observational cohort studies show that persons with a CAC score >100 and who are at low bleeding risk, experience a net benefit with low-dose aspirin, with lower risk of MACE compared with bleeding. In the MESA study (Cainzos-Achirica and Nasir, PMID 32151147), among participants with a CAC>...