Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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 haven't used topical resorcinol, but Joslyn Kirby shared this list of compounding pharmacies that can provide it: Custom Prescriptions of Lancaster Good Day Pharmacy Chambers Apothecary Hazle Compounding Pharmacy Cumberland Apothecary She said it's usually ~$50 for 30 grams of resorcinol from Cu...
When would be the appropriate time to refer an asymptomatic young adult with unicuspid AV s/p valvuloplasty during adolescence for AVR following exercise stress TTE findings demonstrating increase in aortic valve mean gradient from 40mmHg to 70mmHg (achieving 15 METS)?
Great question and the correct answer is: ALWAYS feel free to refer a complex case like this to advanced pedi/ACHD centers. In terms of whether the patient will need or get a prompt AVR… it DEPENDS!First, we need to prove severe aortic stenosis (mean of 70 mmHg seems legit). As is often the case in ...
Do you ever consider using a higher dose of upadacitinib (30 mg daily) for rheumatoid arthritis in patients who fail to respond/partially respond to established dosing of 15 mg daily?
The FDA-approved dose of upadacitinib (UPA) for the treatment of RA is 15 mg per day. In other diseases, such as psoriatic arthritis (PsA), atopic dermatitis (AD) and ulcerative colitis (UC), higher doses (30mg and 45 mg per day) have been studied and shown to be efficacious and relatively safe when...
Would you consider using a JAK inhibitor in combination with an IL 23 inhibitor in cases of severe psoriasis, psoriatic arthritis, or axial spondyloarthritis that is refractory to multiple biologic DMARDs?
Differential skin and joint responses in psoriasis, PsA and Axial SpA are not uncommon. Many PsA/PsO experts and scientists have postulated the potential benefit of using combination biologic (perhaps in serial fashion or lower doses of each) to treat these cases where there are suboptimal responses...