Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What treatment options do you recommend in a patient with idiopathic granulomatous mastitis that has not improved on steroids and methotrexate?
I have multiple cases of IGM that I have treated successfully and have gone into remission or at least not needing any prednisone with azathioprine monotherapy and combo methotrexate and adalimumab.
Do you recommend monitoring IgG level in patients with AAV receiving rituximab?
Yes! At the OSU Vasculitis clinic, we check IgG before every rituximab infusion. At a minimum, it must be done yearly to ensure no impending CVID or to change rituximab.
How do you manage immunosuppressive medications in patients who develop a pneumonia?
For most bacterial pneumonia in transplant patients, I prefer to avoid changing immunosuppressives and simply administer appropriate antibiotic therapy. This approach is effective and minimizes the risk of triggering acute rejection. For viral etiologies, I will often reduce or hold cell cycle inhi...
How would you approach peri-operative immunosuppressive management of a patient with Behcet's, currently controlled on azathioprine, who needs genital surgery?
It might be helpful to know what kind of genital surgery is planned and why. Here are a few general thoughts: There are little data to guide a unified approach outside of BD patients who need vascular surgery. Standard rules of thumb are to 1) reduce surgeries to a necessary minimum and 2) regard mo...
How do you approach treatment of PMR in a patient who has had avascular necrosis of the hip after starting steroids?
In this clinical scenario, I strongly advise avoidance of steroids. The data looks promising for using anti-IL-6 therapy in PMR. I don’t think it should be considered first-line therapy for our patients yet but should be reserved for those who have major contraindications or issues regarding the use...
How do you treat a patient with warfarin failure, with therapeutic INR 2-3 at the time of DVT, and no underlying malignancy or hypercoagulable state?
I would give DOACs a shot in this case. The INR of 2-3 at the time of DVT "Diagnosis" might have been <2 at the time of DVT "development/occurrence" depending on how frequently the INR had been checked. I would, of course, maximize risk factors control as well.
For a patient with osteopenia or osteoporosis, how long can intravenous zoledronic acid be maintained if there are not adverse events?
I generally prescribe Zoledronate annually for three years for patients with osteoporosis who are at increased fracture risk. I will occasionally add an additional treatment 18-24 months after the third infusion if there has been a positive response to the original treatment regimen and I feel that ...
How would you manage a patient with recurrent calcium phosphate nephrolithiasis who has hypercalciuria, hypocitraturia, and a urine pH greater than 6.3?
Good question! Calcium phosphate stone formers are the second most common type after calcium oxalate stone formers. The underlying problem is an elevated urine pH. Your differential diagnosis will include primary hyperparathyroidism, renal tubular acidosis, medullary sponge kidneys and the use of al...
How would you approach a woman with APLA but no thrombosis/APLS, a history of ITP without bleeding who is now pregnant?
As a rheumatologist, I would want to make sure this patient does not have SLE. If no suspicion for SLE (and no previous obstetric complications), I would mostly likely monitor closely during pregnancy without any additional interventions.
When would you consider initiation of bempedoic acid for statin intolerant patients (i.e. LDL threshold, comorbidities)?
Monitor bempedoic acic as you would a statin. I will usually check LDL-C response as well as LFTs within 3 months of starting.