Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach the treatment of checkpoint-inhibitor-mediated temporal arteritis?
Temporal arteritis or GCA is a rare immune related adverse event due to immune checkpoint inhibitor (ICI) therapy. Corticosteroids are the first line treatment, along with holding the ICI. As there have been limited cases, there is not evidence for IVIG in this setting.
How does the presence of nonalcoholic fatty liver disease (NAFLD) impact your choice of csDMARD for RA?
Excellent question and one that comes up often in practice. For the sake of discussion, let's assume hepatitis B and C serologies are negative and there is no suspicion of viral hepatitis. The presence of NAFLD has a direct impact on my choice of csDMARD for RA in this way: if there is significant l...
Are there certain subsets of ANCA vasculitis patients for whom you would consider life long maintenance therapy?
Overall the field is moving towards longer, and sometimes indefinite maintenance therapy. This is because multiple studies have demonstrated that relapse risk increases when maintenance therapy is stopped. I consider indefinite maintenance therapy for the following patients: 1. Frequent relapsers - ...
How would you manage a patient with antiphospholipid syndrome in the setting of severe steroid-refractory thrombocytopenia?
Dr. @Dr. First Last answered the question of severe thrombocytopenia in a patient with APS and an acute thrombotic stroke. I agree with his approach. However, this “between a rock and a hard place” clinical scenario does also appear not infrequently during the chronic management of patients with APS...
What is your approach to using apremilast for psoriatic arthritis in patients with history of depression?
Depression is a common comorbidity of psoriasis and psoriatic arthritis (20% at least mild and 14% at least moderate in a recent meta analysis). Depression is a known but relatively infrequent side effect of apremilast (<1.8% in clinical trials). It is important to screen for depression in all patie...
How do you approach NSAID use in patients on SSRIs?
This is a good question, the combined RR for NSAID+SSRI/GI complications is ~12. I generally avoid the combination and utilize topical NSAIDs if possible. I also discuss the possibility of switching patients from a 'traditional' SSRI to duloxetine, which is FDA approved for the treatment of primary ...
How do you approach management of patients with active RA and recurrent non-severe C.diff?
I think the question here is why the patient is experiencing recurrent C.diff. Is it true recurrence or it never fully clears? Any IgA deficiency? CVID? I would do an immune deficiency work up- complements, immunoglobulines and flowcytometry, response to pneumococcal vaccine. In parallel to the wo...
How would you manage asymptomatic osseous sarcoidosis of the lumbar spine without any other systemic involvement?
Some patients with sarcoidosis are found to have bone-related abnormalities. These are frequently incidental findings often detected as a phantom abnormality on PET or MR scan without corresponding X-ray or CT abnormality; this suggests they are foci of inflammation localized within bone marrow and ...
Do you avoid the use of hydroxychloroquine in patients with psoriasis and/or psoriatic arthritis?
There are many effective medications for PsA out there now that don't have the risk of making their skin disease worse as is the case with HCQ. Patients are also less compliant with daily pills. To me, 1 in 10 is an unacceptably high number to flare their skin.When viewing through a historical lens,...
Do you offer adjuvant radiation therapy for a breast cancer patient with dermatomyositis?
This is an exceptionally important question for clinicians. I'm a little biased as I run an autoimmune Myositis Clinic, but here are my two cents: Paraneoplastic dermatomyositis (DM) is a fairly common occurrence (roughly about 15% of all DM cases, but up to 30-40% in some subtypes, such as adult pa...