Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider an osteoporosis medication in a pre-menopausal/young patient with a low Z score and an ongoing risk factor for secondary osteoporosis such as chronic antiepileptic treatment?
Osteoporosis prevention is always difficult in young patients with risk factors. For young premenopausal women or men below 40, I extrapolate from glucocorticoid-induced osteoporosis (GIOP) guidelines. If Z scores are below -3 and/or there is a history of fragility fracture(s), then treatment with O...
Do you have any suggestions about how to improve rheumatology training in internal medicine residency programs?
As an academic rheumatologist and also an internal medicine program director, I have a strong vested interest in promoting rheumatology. Our clinics are set up so residents have the opportunity to work with varied preceptors to encounter a wide array of pathology as well as practice styles. We have ...
Would you consider starting IVIG as initial steroid-sparing agent instead of azathioprine/methotrexate in a patient with inflammatory myopathy, high Jo-1, weakness with severe dysphagia and without skin involvement or ILD?
Yes, that would be one approach especially given severe dysphagia. The best treatment for dysphagia is IVIG. However, steroid + MTX/AZA would be a reasonable approach for 2-3 months. If not seeing desirable results, going for IVIG early rather than late would be a good strategy as well.
What is your work up and management for patients who develop neuropathy on a TNF inhibitor?
The first issue to address is whether the neuropathy is truly related to the TNF blocker. This can be challenging as many of our patients who were prescribed these drugs may have an underlying neuropathy related to their disease. For example, we know that patients with RA are susceptible to developi...
Do you recommend on-demand versus fixed-schedule dosing for rituximab maintenance in ANCA vasculitis?
This is a fairly hot question in the field, and one that reflects the success we have had with advancing therapy for ANCA-associated vasculitis; it’s nice to have choices! Although there are data for both approaches, there are more data (larger numbers, etc.), in my opinion, for fixed-dosing. The tr...
What clinical factors do you use to determine timing of on-demand dosing of rituximab in ANCA vasculitis maintenance therapy?
I tend to use scheduled dosing (q 6 months) with RTX for maintenance in my GPA/MPA patients, but will occasionally use "on-demand" dosing in those who are eager to minimize their RTX, do not tolerate the infusions well, or occasionally those who have lower risks of flare (mild disease, no history of...
Is romosozumab an option in a patient who has completed 2 years of teriparatide therapy and has a fracture while on denosumab?
Romosozumab would be an excellent option in this setting. Although both teriparatide and romosozumab are anabolic agents, they have different MOAs and there is no cumulative time limit of therapy as there would be in the case of additional therapy with abaloparatide. At the completion of therapy wit...
What are some strategies for radiographically differentiating between erosions secondary to erosive osteoarthritis versus psoriatic arthritis involving the DIP joints?
In erosive OA, DIP changes show central (or paracentral) erosions with gull-wing appearance. Gull-wing appearance is created by the sclerotic border of erosion in OA (sclerotic border is typically not present in PsA). In addition, at least DIPs are involved in OA (Ridley et al., PMID 30309145).In Ps...
What steroid-sparing agent would you use for treatment of neurosarcoidosis with leptomeningeal and parenchymal involvement?
I am a strong proponent of infliximab for many cases of CNS neurosarcoidosis, particularly in more urgent cases. My experience is that response can sometimes be quite prompt, certainly in comparison to more conventional agents, and I have seen clinical and radiological improvement even during the in...
What do you use to treat a GCA patient refractory to methotrexate who responded but had adverse effects with both tocilizumab and sarilumab?
This is a challenging group and we don't have a clear answer. Aside from stretching their steroid taper, which is always an option, alternative off label therapies could be considered. From conventional DMARDs, you could try leflunomide. The IL12/23 inhibitor ustekinumab has been studied and has had...