Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
What is the most appropriate next step in management for a patient with dermatomyositis who is maintained on methotrexate 25 mg weekly but develops disease flare when prednisone is tapered below 10 mg daily and is unable to receive IVIG?
The fact that the patient cannot taper prednisone below 10 mg indicates that methotrexate alone, while has some effect, is not sufficient to control the disease. There are several options, depending on the severity of each organ involvement. Since the joints are affected, I would favor an agent that...
Are the results of the SEAM-RA trial generalizable to other TNF inhibitors given the differences in immunogenicity?
This is a great question, and an important one because different TNF inhibitors have different immunogenicity and patients can make anti-drug antibodies that can effectively neutralize the drug and render it a less effective treatment option. This tends to happen more with some molecular constructs ...
For patients with evidence of prior bilateral uveitis (PS, pupillary membranes, inactive KP, no view posteriorly) who reports no prior symptoms and who has had negative lab work-up, when do you consider repeat work-up and which labs would you repeat?
This is a difficult question to answer succinctly, as so much information is missing to provide a complete response. However, it does raise some important points that are worth mentioning:There is a prevailing tenet, which I was taught as a resident and hear often from residents today, that 1st epis...
Is there any role for prophylactic DMARD therapy to prevent immune-related adverse events (irAEs) in patients receiving immune checkpoint inhibitors?
Excellent and timely question!There are no good studies-- but I truly believe this is where we are heading for cellular therapies and IO. I am unsure if it will be DMARDs, as lung cancer patients get premetrexed with IO and still develop irAEs-- it will more likely be bDMARDs.The reason, I believe, ...
What is your approach to management of recurrent Kikuchi-Fujimoto Disease?
My experience with recurrent Kikuchi–Fujimoto disease (KFD) is limited, as I have not managed many recurrences; however, this is the general framework I use in practice. At the time of a recurrence, I first reassess the diagnosis and consider potential mimics—particularly infection, lymphoma, and ev...
In patients with relapsing polychondritis with suboptimal response to NSAIDs and prednisone, what are strategies you use for flare treatment?
It depends on multiple variables, including organ involvement, disease activity, and associated manifestations. I would be happy to discuss it further if you would like.
What is the role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
What minimum clinical features or risk factors drive you to obtain a baseline HRCT in a patient with RA or Sjogren's disease?
Overall, about 10% of RA patients will develop clinically significant ILD, as will 20% of those with SjD. Those are a significant number of people, and ILD should be on our radar as clinicians. Knowledge of risk factors for ILD can help us focus on people most likely to be affected. Several risk fac...
How do you approach management of chronic cough in patients with ILD?
By the time an individual presents with ILD and cough, and fibrotic therapy has started, there’s almost no use for increasing the dose to treat cough instead of a neural modulator such as gabapentin, and if cough is interrupting sleep, low-dose narcotics. The spinoff is that narcotics may reduce dia...