Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there any role for direct oral anticoagulants in the treatment of antiphospholipid syndrome?
Triple-negative APS is a confusing category as includes seronegative APS, APS with non-conforming aPL such as anti-phosphatidylserine-prothrombin amongst others, and the universe of patients with thrombotic events unrelated to antibody-mediated hypercoagulable state (eg Protein S, C or anti-thrombin...
Would you continue TNFi for inflammatory arthritis if the patient develops a solid organ malignancy while on that therapy?
In nearly all cases, I would stop the TNF inhibitor (TNFi). Though there is no evidence that these drugs raise the risk for solid organ tumor, the clinician must tread cautiously. First, the patient may require other potentially immune-suppressive anti-cancer therapies (plus radiation in some cases)...
What is the preferred DMARD in active spondyloarthropathy with psoriasis and sacroiliitis features in the setting of treated hepatitis C with negative viral load?
Given that the patient is treated and has a negative viral load, options for treating PsA are rather broad. Of course, if high-risk behaviors that increase the risk of developing hepatitis C persist, the options are very limited. In the anti-TNF class, I prefer etanercept due to its short half-life....
In what situations do you check for HIV status in your workup for inflammatory arthritis?
This brings up a great point - HIV screening is recommended for all patients at least once, and more frequently if the patient has risk factors for HIV. Seeing a patient in the clinic is a great opportunity to ensure they have been screened appropriately for HIV. In rheumatic disease situations, HIV...
Do you extrapolate from uveitis treatment pathways when managing other inflammatory eye conditions such as atypical serpiginous choroiditis?
I do tend to apply these principles. So these entities like serpiginous, relentless placoid, etc., I would consider posterior uveitis. While we definitely do not fully understand the full pathophysiology of all these diseases, there is good evidence of inflammatory activity, hence response to steroi...
What would be your differential for a wrist monoarthritis in an elderly female with erosions on MRI after less than 3 months of symptoms?
I would put CPPD arthritis high on the differential, as the wrist is a common site for CPPD arthropathy in the elderly. In the right context, septic arthritis is a possibility, particularly if the patient is immunosuppressed. Indolent infections such as fungal or mycobacterial are possibilities. Les...
What would you use to treat polymyositis refractory to high dose steroids, methotrexate, mycophenolate, IVIG, and cyclophosphamide?
Refractory polymyositis might be a red flag for an alternate diagnosis, like IBM or genetic muscle disease, especially in the absence of a myositis specific antibody, like SRP or HMGCR (the most common antibodies in PM/immune-mediated necrotizing myopathies). If IIM is confirmed, then a combination ...
Is it safe to treat checkpoint inhibitor-induced arthritis with methotrexate or biologics?
How the safety of methotrexate or biologics compares to long term steroid use to treated checkpoint-inhibitor inflammatory arthritis has not been determined. With that said, steroids can have deleterious effects on the tumor response in addition to all the other known side effects. Therefore, for pa...
What is your approach to bladder cancer surveillance in patients who have received cyclophosphamide?
Risk of bladder cancer following cyclophosphamide treatment can be associated with oral therapy and likely also related to cumulative dose (1). Risk of bladder cancer with intermittent IV cyclophosphamide has been reported in some observational studies, but has not been consistently reproduced (2). ...
Do you follow patients with elevated ESR/CRP if their work-up for rheumatologic etiology is unrevealing and no other cause is identified?
The short answer is yes for most cases. That said, there are many variables. Typically, elevations in acute phase reactants (ARPs) occur in response to different initiating events and can be observed to resolve on repeat testing. Persistent elevations in ARPs in the absence of clinical signs and sym...