Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach pain management in patients with idiopathic polyneuropathy?
There are a few different guidelines/recommendations depending on which professional society you search. However, I tend to adhere most closely to the table cited below, with an approach that looks something like: First line: Gabapentin 300mg TID titrating up to 1000mg TID Pregabalin 75mg BID titra...
What is your approach to discordant dsDNA testing, such as positivity to dsDNA by crithidia but negativity to dsDNA by other modalities?
What a great question with many facets. The information I provide is meant to be very practical. These answers are from the viewpoint of a rheumatologist and not an immunologist. I discussed this subject with Dr. Debra Zack, a rheumatologist/immunologist who is an expert with anti-dsDNA, and I had t...
Do you assess baseline salivary gland function before starting treatment in patients with Sjogren's syndrome?
No. Visual assessment of salivary pool and oral mucosa is routinely done. In the initial consultation and management plan, most always, referral to Sjogren's Oral Medicine Specialist is made where whole salivary flow is measured, usually by Unstimulated Whole Salivary Flow Rate (abnormal, less than/...
When considering the use of DOACs in APLS, does the number of positive APLS antibodies influence your decision?
The number of antibodies is an important consideration.On the one end of the spectrum, I would not recommend any DOACs in a triple positive APLS (especially with arterial thrombosis). Having said that, I would not change treatment in a triple positive APLS patient if they were started on DOACs in th...
Do you always initiate hypercoagulable work up in a patient with recurrent stroke?
As always, this is a more complex problem than it appears. A history of both prior other thrombosis and family history of thrombosis is essential. Are there good reasons for the stroke and/or has it been worked out in past including carotid disease, atrial fibrillation, underlying malignancy, valvul...
How will you treat a young man with recurrent cryptogenic strokes with no identifiable cause, with MTHFR A1298C homozygous mutation and normal homocysteine level?
The genetic variant you report seems to be a SNP that, while it has been reported to be statistically associated with various diseases in GWAS studies, is not pathogenic. SNPs that are significant in GWAS studies have very small effect sizes that can be measured when considered in thousands of peopl...
Can lupus anticoagulant be positive despite a normal aPTT?
aPTT is one of the assays that may be abnormal in the presence of lupus anticoagulant, but not always. Usually, when screening for lupus anticoagulant, there will be a "special" aPTT assay used that is a bit more sensitive to detect lupus anticoagulant. There are several different aPTT-based assays ...
Should HCQ be continued in an asymptomatic SLE patient who has received renal transplant?
As far as I know there is not a definitive answer to this question due to a lack of clinical trials. My approach is to continue it at a dose adjusted for renal failure. My thought process is that both lupus and chronic renal failure increase the risk of cardiovascular events significantly. Plaquenil...
Do you prefer using losartan in your patients with hypertension and gout due to its uricosuric effects?
I do find losartan helpful. It is especially helpful asking a PCP to change HCTZ to losartan. Though the losartan's urate-lowering effect is a small amount, I combine this with dietary changes (especially greatly limiting the intake of foods high in fructose) and eating purines in moderation, and e...
Do you still consider the use of pegloticase in someone with substantial tophaceous burden despite optimal uric acid levels?
If a patient has a significant burden of tophaceous deposits causing functional impairment despite serum uric acid control achieved through oral uric acid lowering therapy (ULT), I strongly recommend considering a course of enzymatic therapy with pegloticase. Terms such as “treatment failure gout” o...