Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you assess transaminitis in a patient with sarcoidosis with known liver involvement being treated with methotrexate?
This can be fairly tough, as you cannot assess for hepatoxicity from methotrexate in a patient who already has a transaminitis. Hepatic sarcoidosis occurs in 11-80% cases and is often asymptomatic. Some patients may have a transaminitis, elevated alk phos, or liver lesions noted on imaging. Serious ...
For which subset(s) of APS patients do you recommend an INR of 3 or higher?
According to the EULAR 2019 recommendations for managing APL (Tektonidou et al., PMID 31092409) and according to the 2011 APL Task Force recommendations: For secondary venous thrombosis prophylaxis, it is recommended to keep INR between 2-3. Patients who fail warfarin therapy at INR 2-3 may benefit ...
Do you avoid any specific biologic therapies in HIV positive patients?
At present, the most safety data on the use of biologics in HIV is TNF inhibitors. CD4 count should be > 200 and VL undetectable. Etanercept is most preferable, give lower incidence of serious infections as well as its efficacy as monotherapy (without methotrexate). Wangsiricharoen et al., PMID 2733...
How do you treat RA in patients with pulmonary mycobacterium avium complex (MAC) infections?
This is a very complex situation and requires teamwork between rheumatology and infectious disease with close patient follow-up and treatment. In general, avoiding TNF inhibitors in these patients is preferred, in particular the monoclonals, with close monitoring. Methotrexate is an option, and in t...
Is antiplatelet or anticoagulant therapy preferred for the secondary prophylaxis of cryptogenic stroke in a patient with underlying malignancy?
Will look at the stroke radiographically. If appears embolic and the patient is low risk for bleeding, with respect to their cancer regimen, co-morbidities, and labs, I will discuss off-label anticoagulation with eliquis. If there are additional, chronic embolic appearing strokes - that will also sw...
What is your inflammatory arthritis differential when a patient presents with unilateral TMJ synovitis?
The differential of TMJ disease depends on the age group. In the younger population, JIA must be very high on the differential. In adults, the differential includes RA, dermatomyositis, systemic sclerosis, systemic lupus erythematosis, and spondyloarthropathies (Ankylosing spondylitis and psoriatic ...
What is your approach to screening for cardiac involvement in patients with myositis and how does the finding of cardiac involvement change your management?
Cardiac involvement in IIM can often be overlooked but reportedly occurs at a high rate (~up to 75%) in a subclinical fashion. This can run the gamut of myocarditis, arrhythmias, conduction defects, cardiomyopathy, heart failure, and atherosclerotic disease. Screening for this often starts with an E...
How does your treatment algorithm differ for drug-induced ANCA vasculitis compared to non drug-induced ANCA vasculitis in cases with severe/organ-threatening manifestations?
When end-organ manifestations are present, my initial treatment approach is similar for drug-induced and non-drug induced AAV and typically consists of glucocorticoids and rituximab, including pulse glucocorticoids with severe end-organ involvement. Common drug culprits such as PTU, hydralazine, min...
How would you attempt to determine the etiology of intracranial hemorrhage in a patient with newly diagnosed lupus and an active viral infection?
My typical evaluation of a case like this is as follows: 1. Evaluate their lupus disease activity: CBC, CMP, ESR, CRP, C3, C4, dsDNA, urinalysis, urine protein/creatinine ratio (latter two are more for eval of renal disease) 2. Evaluate the cause of ICH: a. MR to further evaluate for other non-ICH r...
How do you counsel Takayasu patients on their prognosis?
Unfortunately, patients with Takayasu arteritis have a higher mortality rate compared to the general population. Most studies suggest a 3-fold higher standardized mortality rate in patients with TAK compared to age-matched healthy controls. Survival rates following TAK diagnosis vary notably between...