Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
How do you approach evaluation and management of arthralgia in a patient after CAR-T cell therapy?
This is a great question - part of cytokine release at syndrome includes joint pain. So my questions are: How far after? What was the reason for the CAR-T? These are vital questions to understand first. To that be said - the answers will determine if you give a one-and-done treatment or long-term....
What is your approach to working up diarrhea in an immunocompromised patient?
Tough question and very common in clinical and research management. The approach is going to mirror any new complaint and start with a history. Diarrhea means many things to many patients/clinical trial subjects, so characterizing duration, frequency in a day, nocturnal events (diarrhea that occurs ...
Is there a role for hydroxychloroquine for secondary prevention in patients with APS without SLE?
There are no prospective trials to answer this question. In one cross-sectional study (Erkan et al., PMID 12154210) there was a suggestion of a protective effect of hydroxychloroquine. However, patients were also on aspirin and it may be difficult to sort out which of these agents had the protective...
How would you manage a patient with stable axial spondyloarthritis who develops newly active IgA nephropathy?
Although the data are sparse, in general, the principles of treatment of IgAN in the setting of spondyloarthritis is similar to primary IgAN. BP targets <120/80 RAS inhibitors or sparsentan SGLT2 inhibitors If persistent proteinuria despite above, targeted-release budesonide or oral corticosteroids ...