Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach methotrexate management around vaccines other than COVID and influenza?
The COVID pandemic has highlighted impaired vaccine responses in our patient populations and current data was nicely summarized in Friedman et al., PMID: 34493491.Evidence had preceded the pandemic regarding diminished response to pneumococcal vaccination in patients with RA on methotrexate. My appr...
How do you approach treating idiopathic aortitis?
Before classifying a patient as ‘idiopathic’ or ‘clinically isolated aortitis’ (CIA), one must carefully consider that the aortitis may be a manifestation of a systemic condition, particularly giant cell arteritis or Takayasu arteritis. Other systemic diseases associated with aortitis include IgG4-...
How would you manage gout with hyperuricemia >10 mg/dl despite the maximum dose of allopurinol plus probenecid and a prior allergic reaction to pegloticase?
I am not sure what dose of allopurinol the patient is taking, how long he was on pegloticase, and if he had MTX or MMF with it. I can usually reduce the uric acid level with allopurinol and febuxostat. The key question here is whether the patient is taking the drug daily or not.
How do you time Evenity after completion of Forteo?
If a physician is considering transitioning an osteoporotic patient from a PTH treatment to romosozumab, there is no reason to delay. It should be fine to start romosozumab immediately upon discontinuing PTH if it is clinically indicated. However, it is important to remember that romosozumab has a b...
How do you approach selecting biologic therapy vs non-biologic DMARD (such as methotrexate) as initial therapy in patients with new RA diagnosis with significant erosive disease?
In my clinical experience, not everyone is the best candidate for methotrexate. Businessmen who feel alcohol consumption is part of their ability to finish business deals are uncomfortable taking methotrexate and I am uncomfortable prescribing for them. Men and women who are hoping to bear children ...
Is there utility in monitoring IgE levels in patients with IgG4-RD?
Serum IgE levels are associated with disease extent/severity and risk of relapse in patients with IgG4-RD. In some patients (although this is not true for all patients), IgE decreases following treatment and increases with disease flares. However, some patients who have extreme IgE elevations at bas...
How do you gain access to quinacrine, and what has your recent experience been?
It can be gotten from a few compounding pharmacies. The cost is high (around $400 a month) and usually not covered by insurance. One compounding pharmacy that often carries it is ChemistryRx in Philadelphia.
How would you approach a patient with axial spondyloarthritis who develops new-onset proteinuria?
I would approach the workup for proteinuria based on the differential diagnosis with leading etiologies including, acute illness, diabetes, nephrotic syndrome (minimal change disease, FSGS, membranous neuropathy), drug-induced proteinuria, vasculitis, and of course IgA neuropathy. Standard studies i...
What would be your approach to a SLE patient who is triple APS positive, has no prior VTE/obstetric events, is stable on HCQ and low dose aspirin, and wants to become pregnant?
As long as lupus is well controlled, I would not recommend making any changes. I would also reassure this patient that having prior successful pregnancies (based on the information provided in the question stating that there were no prior obstetric complications) is a good sign. I would not prescrib...
Is it ever appropriate to restart bipshosphonates following a drug holiday in a patient with a prior atypical hip fracture?
I agree with Dr. @Dr. First Last. I am not likely to ever prescribe a bisphosphonate after someone has had an AFF (or ONJ) attributed to the bisphosphonate. Anabolics make sense if you can get them paid for. Raloxifene is fine but there is no evidence for non-vertebral fracture risk reduction. Venou...