Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Are stress-dose steroids indicated in patients with adrenal insufficiency receiving radiation therapy?
I am not aware of any direct analysis or study that has addressed this question specifically for patients undergoing radiation treatment, but I can comment on the present indications for perioperative stress-dose glucocorticoids in adrenally insufficient patients, from which certain inferences to Ra...
In gout, do MSU crystals form only in tissue, or are there circulating microcrystals of MSU within blood vessels?
The solubility of MSU is dependent upon solute, temperature, and pH. Even with a rapid rise in total body uric acid as seen with tumor lysis syndrome, where uric acid levels can exceed 15 mg/dL, I have never heard of an MSU crystal identified in a serum sample. As I explain to students and patients,...
Is it ever appropriate to use hydroxychloroquine temporarily in higher doses (more than 5mg/kg) to control lupus activity such as skin manifestations?
The risk of retinal toxicity with long-term use of doses higher than 5mg/kg was shown by Melles and Marmor; PMID 25275721. There are reports of developing retinal toxicity even with short-term use of HCQ mostly coming from oncology literature (e.g. Navajas et al., PMID 26651304).There is some publis...
Is there an increased risk of COVID-19 in patients on immunosuppressants?
This is an important question to which there is no clear answer. Intuitively, it would be expected that patients who are immunosuppressed would be at greater risk of Covid infection. However, observational studies suggest that this may not be the case. Haberman et. al., have reported the results of ...
Would you hold all immunosuppressive medications for the first month of LTBI treatment, or just biologics?
This video might answer your question: QD Clinic - Lessons from the clinic - Dx and Treating LTBI with a TNFI inhibitor features Dr. Jack Cush
How do you manage hand-foot syndrome associated with capecitabine (and other conventional chemotherapy agents)?
In the breast cancer world, I see hand-foot syndrome most commonly with capecitabine. I have used topical 10% urea cream with a reasonable amount of success. I have noticed that using it prophylactically seems to help with the prevention of hand-foot syndrome to quite an extent. A couple of randomiz...
How do you manage early rectal symptoms such as tenesmus in a patient undergoing pelvic radiation for prostate cancer?
If patients are having symptoms out of proportion to what you would expect, I consider other potential causes, especially if the usual management approaches aren't working. I've had a few patients over the years with undiagnosed Celiac disease, who got severe early diarrhea during a course of extern...
Which immunosuppressed patients with SLE would benefit from antibiotic prophylaxis to prevent pneumocystis pneumonia?
Starting PCP prophylaxis in patients with lupus is controversial. We typically start lupus patients on PCP prophylaxis if they have underlying ILD and are on doses of steroids of 20 mg or higher. I also consider starting PCP prophylaxis in lupus patients while they are receiving cyclophosphamide and...
Should venous thrombosis in a patient with Behcet syndrome be treated with both immunosuppression and anticoagulation?
They should be treated with immunosuppressive medications, however, the additional benefit of anticoagulation is much debated. Various studies and metaanalysis have shown that anticoagulation, on average, does not add any benefit. There may be exceptions to this in the early part of treatment for so...
Is there a role for PCSK9 inhibitors in patients with statin-associated immune mediated necrotizing myopathy?
The majority of patients with statin-associated immune mediated necrotizing myopathy are in need of cholesterol-lowering medications. While one can try other strategies (like diet or ezetimibe), these are usually inadequate. Therefore, I would advocate for PCSK9 inhibitors as first-line treatment, w...