Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach low to moderate titer of APLS when working up unprovoked DVT if it is persistent on repeat testing?
I have a low threshold to recommend long term (indefinite) anticoagulation for unprovoked thrombosis, regardless of whether there is positive APLS testing. I do agree with Dr. @Dr. First Last, however, that shared decision-making is important when committing a patient to prolonged anticoagulation, a...
What is your approach to managing RA patients with history of organ transplant already on immunosuppressive therapy such as cyclosporine or cellcept?
In contrast to my esteemed colleague, @Dr. First Last, in 38+ years in clinical rheumatology practice (maybe those 3 years make a difference), I have seen RA occur in 3 patients with solid organ transplants. All 3 were renal transplants; all 3 were recurrent diseases that had been previously control...
What is your approach for using anticoagulation/aspirin in patients with multiple myeloma?
Excellent question with lots of nuances but no clear answer. I'll start with my gestalt approach, which is to consider a DOAC for every patient with myeloma if all of the following are true: They are receiving an IMiD (lenalidomide or pomalidomide) They set off my 'spidey sense' with one or more of ...
Are there any possible scenarios where you would do phlebotomies for heterozygous hemochromatosis?
The answer is yes but unusual. Occasionally, a heterozygote or double heterozygote will be weakly phenotypically positive. If the ferritin and TSAT (on overnight fasting sample) are high, I will. I prefer that blood donation be used but if not an option, I will take it. The iron parameters must be...
How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?
Our hematologist/oncologist referred just such a patient. No evidence of malignancy, but elevated CRP &ESR. I did an “internist’s” workup as I would for dermatomyositis, starting with the most important and therefore most thorough aspect: taking a full and very “invasive” history, followed by a comp...
What is your approach to the diagnosis and management of lupus cystitis?
Lupus cystitis is a rare complication of lupus but there does appear to be an association. I depend on the urologist to confirm the diagnosis of interstitial cystitis. If mild to moderate in activity, will use standard treatments for cystitis with bladder infusions, bladder relaxants in collaboratio...
What labs do you order to monitor patients on JAK1 inhibitiors (abrocitinib or upadacitinib)?
TB, HepB, and HepC at baseline, never repeated. CBC, CMP, and Lipids at baseline and 3 months, then once a year. CMP is probably unnecessary - no hepatic or renal toxicity - but I still do it. WBC and Hemoglobin often go down a little bit, but always happens in the first 3 months. Have had 2 patient...
What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?
This is an important concept because anyone using tocilizumab will eventually wrestle with this question. The question, though, does not tell you whether this is the first time a practitioner sees the liver enzyme elevation, or how high the liver enzymes rose. Since everyone should have had a lipid ...
Does your approach to the management of a patient with an acute exacerbation of CPFE where the ILD is attributed to IPF differ from the management of a patient with an exacerbation of IPF alone?
In general, once an extensive workup to exonerate alternative causes of ILD in patients with presumed CPFE has been performed, I tend to treat the interstitial component of these two entities similarly, whether in the chronic phase or during an acute exacerbation. Smoking is a well-known risk facto...
How should elevated PT of unclear etiology and significance be evaluated?
Mild prolongation of the prothrombin time (PT) may represent a normal ‘outlier’. If there is no obvious explanation for a moderate to marked prolongation of the PT (for example, anticoagulation therapy effect, liver disease, nutritional deficiency like vitamin K deficiency. then the next step is to ...