Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you consider it safe to continue adalimumab for spondyloarthritis in a patient who develops localized melanoma if the adalimumab has worked well?
This is a challenging question as there's a lack of data regarding the impact of anti-TNF agents on melanoma progression. While the safety record for TNFi in the context of malignancy is generally positive, melanoma progression remains unpredictable. In the described case of localized melanoma, my p...
How do you approach an older male with a chronic and persistent granulomatous cutaneous medium vessel vasculitis that has been unresponsive/worsened on high dose steroids, cyclophosphamide, and rituximab immunosuppressive agents with a thorough and unremarkable serologic, infectious, and imaging work-up?
These types of patients vex all rheumatologists at one time or another during the course of clinical practice. The primary concern that is usually raised by a rheumatic disorder unresponsive to therapy is a paraneoplastic disorder. When you say you have a “thorough imaging work-up,” what do you mean...
What kinds of dental work do you particularly worry about and try to avoid in patients on bisphosphonates?
Firstly, the incidence of BRONJ (bisphosphonate-related osteonecrosis of the jaw) is very low with all drugs of this class. However, many patients and dentists are concerned about the possibility of this problem. Generally, BRONJ occurs after an extraction and subsequent poor healing at the extracti...
What is your approach to assessing whether oral/nasal ulcerations are features of systemic lupus erythematosus versus from another etiology?
Mucosal ulcerations due to lupus erythematosus (LE) are more complicated than many of us think. So, this question and answer are not as straightforward as many think. First, the subtitle to this question is misleading. I would not use the word "blister," a lay term that I usually reserve for vesicle...
What indicators do you use to determine whether a patient is having a favorable or unfavorable response to nintedanib?
Unfortunately, there probably isn't a way to do this. It might be helpful to step back and see what nintedanib buys you: as compared to placebo, the nintedanib group suffered less FVC decline by ~110mL/year. Real-world data suggest there's probably a mortality benefit if you have your patients on it...
How do you counsel patients on the benefits of diet and exercise in OA in a way that motivates them to comply?
Although this issue is critically important for the care of patients with knee OA, the question itself is a bit disingenuous, as long-term behavior modification is very difficult to achieve on a population level. There is abundant evidence that exercise and strengthening of the periarticular muscula...
How do you counsel patients who prefer to continue TNFi therapy indefinitely for rheumatoid arthritis despite long-standing remission?
I explain the risk of stopping and having a return of disease after stopping (that this could be a “drug holiday” of limited duration) and that this return of disease activity may not respond to restarting the TNF blockade therapy that had been working well for them. Then they would have to start a ...
Do you recommend Vitamin D and omega 3 fatty acid supplementation for prevention of autoimmune disease?
A resounding "Yes!" but with caveats. I do not recommend them independently but as part of a list of recommendations (listed below).There is mounting data that many autoimmune disorders (especially systemic lupus erythematosus, SLE, and rheumatoid arthritis) probably occur due to environmental (exte...
How can ethnic representation in clinical research studies in childhood and adult SLE be improved?
This is the million-dollar question. It will take multifaceted approaches. I think while ironically it should be easier to enroll children with lupus into clinical trials given more pediatric rheumatologists are in academic practices, children are a protected group and as such few clinical trials ar...
What is your approach to differentiating and managing DMARD-induced nodulosis (induced by methotrexate or leflunomide for example) from "de novo" RA nodules in seropositive RA patients?
Though there are some clinical distinctions that may help to differentiate RA-related nodules from those associated with either methotrexate (MTX) or leflunomide (LEF), one may never be fully certain. RA-related nodules tend to be bigger and fleshy to palpate whereas drug-related nodule formation is...