Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
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 ...
When is the index of suspicion high for paraneoplastic systemic sclerosis in terms of clinical and serological presentation and how will you work it up?
This is a great question. Data on the risk for malignancy in newly diagnosed scleroderma patients has been emerging for the past 10 years or so. To date, it appears that the strongest risk factors may be autoantibody with RNA polymerase 3 antibodies showing consistent increase in risk amongst sclero...
What is your approach to patients who present with unilateral Raynaud's?
Thank you for that excellent question! Typically, Raynaud’s phenomenon impacts multiple digits of both hands (and often feet; sometimes tip of the nose, ears, nipples) and is often symmetric in the case of primary and can be asymmetric in Secondary Raynaud’s (often sparing the thumb). In some cases,...