Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to treating crowned dens syndrome?
Crowned dens syndrome is said to account for as much as 2% of acute neck pain. The diagnosis is mostly clinical. The patient will present with acute neck pain, elevated acute phase reactants, calcific deposits overlying the dens on x-ray or CT scan, and the lack of an alternative diagnosis. In >40 y...
What is your approach to management of chronic neutropenia in a patient with Sjogren’s who was recently diagnosed with metastatic endometrial cancer and plans to start chemotherapy?
With metastatic cancer, optimal treatment of the endometrial cancer is the priority. Heme/Onc consultant would likely be giving granulocyte stimulating products.Although neutropenia can occur in Sjogren's Disease (SjD), I rarely have found it to be clinically significant, and lymphopenia seems to oc...
Is there a reason to repeat HMGCR antibody level for monitoring disease activity once documented positive in patients with IMNM?
HMGCR antibody persists even when the disease is quiescent, and levels of the antibody correlate with the log of the CPK levels. Therefore, it is not a very sensitive marker for disease activity, so it is not a useful marker to follow longitudinally. Instead, CPK is a cheaper and more sensitive mark...
Do you typically screen patients for antiphospholipid antibodies in autoimmune diseases besides lupus in the absence of a clotting event?
I would check antiphospholipid antibodies (APLAs) in a few situations in the absence of thrombotic events: 1. In someone with other APS manifestations: Obstetrical complications (especially) APL nephropathy noted on renal bx Unexplained adrenal hemorrhage/microthrombosis Non-infectious endocardial v...
How would you counsel a patient who is interested in using supplements (such as fish oil or turmeric) as an adjunct to treatment of inflammatory arthritis?
Drs. @Dr. First Last and @Dr. First Last expertly raise the key difficulty rheumatologists face with herbal medications: imparting a healthy respect for the potential risk:benefit (and limited data) about these agents against allowing patients to erroneously characterize their physician as close-min...
Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?
Great question, with practical implications for the clinic: Azathioprine (AZA) is a prodrug that likely exerts its immunosuppressive effects against B- and T-cell function by interfering with purine metabolism through its metabolites (including 6-MP). Logically, many of the "classic" AZA side effect...
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...