Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there a role for ultrasound in assessing for "clinically silent" inflammatory arthritis prior to tapering DMARD therapy?
This is an excellent question. Data have been mixed with regards to the significance of sonographic synovitis (grayscale or Doppler) in "clinically silent" patients on immunosuppression. Initially, the question was asked in earlier papers whether such patients warrant an INCREASE in their immunosupp...
What agent would you choose for a patient who needs osteoporosis therapy after a bisphosphonate holiday?
This is a question of high clinical importance but with a lack of good controlled data. First and foremost, a holiday should be viewed as a temporary discontinuation of therapy. Anecdotally, I would say about 30% of my patients need to go back on therapy. There is a lack of data to support clinical ...
When suspecting a diagnosis of complex regional pain syndrome (or reflex sympathetic dystrophy), what workup should be done to confirm or exclude it?
Every evaluation begins with a thorough history and physical, particularly to look for other explanations of pain to this region. In my opinion, unilateral symptoms are much easier to assess than bilateral symptoms. Bilateral CRPS is reported but it is quite unusual. I am more likely to support a di...
In patients with knee osteoarthritis, do you recommend the use of hyaluronate injections if it is available and affordable for the patient?
This is a very controversial topic because the data simply hasn't been convincing. Many professional medical societies have either rejected HA or recommended it conditionally (or recommended against it conditionally). That being said, the literature has plenty of case series and reports of great rel...
How do you differentiate between axial psoriatic arthritis and axial spondylitis with psoriasis, and is it important to distinguish between these two conditions from a prognostic and treatment perspective?
This is an ongoing controversy in the field(s), with some studies suggesting that clinical differences allow differentiation of axial involvement in psoriatic arthritis from classical ankylosing spondylitis. The concept was recently the topic of a study by Feld and colleagues published in Rheumatolo...
Do you choose rituximab or calcineurin inhibitors for patients with class IV/V lupus nephritis who are refractory to standard of care therapies?
In severe active lupus nephritis, I use rituximab for refractory cases although tacrolimus is an option with published data for induction of lupus nephritis. There have been some instances where I have used both medications together. Things to keep in mind when making this decision include the prof...
Do you use hydroxychloroquine for prevention of neonatal lupus in patients with a positive SSA who are planning on becoming pregnant?
There is some evidence that hydroxychloroquine can prevent CHB in patients at high risk (mothers who already had a fetus with CHB in a previous pregnancy (Izmirly et al., PMID 32674792). There is scant evidence about neonatal lupus and the use of HCQ to prevent it. HCQ is generally well-tolerated an...
Is chronic major salivary gland enlargement in a patient with Sjogren's an indication for immune-modulating therapy such as hydroxychloroquine or methotrexate?
Although there have been 2 patients reported to have an improvement in parotid size with hydroxychloroquine and methotrexate are generally ineffective for the treatment of chronic bilateral major salivary gland enlargement in Sjogren's. For acute bilateral swelling, a tapering dose of prednisone can...
How do you treat small fiber neuropathy associated with rheumatic conditions like Sjogren’s syndrome?
Have primarily followed the recommendations of Julius Birnbaum's group from Hopkins Sjogren's Center and use neuroleptics, primarily gabapentin. The main issue for Sjogren's patients with significant sicca symptoms is that many of the options we have for neuropathic pain increase dryness symptoms, s...
How do you counsel patients who ask you about trying oral or topical formulations of medical marijuana for pain related to arthritis or fibromyalgia?
Despite the acknowledged widespread use of cannabis in rheumatology patients, there has been no evidence of its efficacy. A recent systematic review of randomized controlled trials found no evidence for the use of cannabinoids, cannabis, and cannabis-based medications in chronic pain management (Fis...