Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you screen dermatomyositis patients for malignancy if they have a high risk antibody profile (NXP-2/TIF1gamma positive) and their initial screen is negative?
If an initial screen is negative, including age-appropriate malignancy screening, the need for additional testing in an NXP2 or TIF1 gamma patient would be driven by the clinical presentation and risk factors. An older patient with severe disease (including dysphagia, ulcerations, vasculitis), refr...
What do you use to treat uveitis refractory to conventional synthetic DMARDs and TNF inhibitors?
I would add support to a trial of intravenous tocilizumab, particularly if macular edema is a feature of the uveitis. The STOP-Uveitis trial demonstrated reasonable efficacy in intermediate, posterior, and panuveitis (STOP-Uveitis) and I have used this within my own practice with success in patients...
What are the most effective therapies for CPPD with a "pseudo-RA" pattern?
That is a great question! The short answer is that we really don't know. There are no good quality RCTs for CPPD. In my experience, these patients are quite difficult to manage. I will often start with low dose prednisone (which almost always works) and then search for a steroid-sparing agent. I sta...
What is the safest approach to treating refractory RA in the setting of an active solid organ malignancy?
In order to best treat refractory RA in this patient with active solid malignancy who has failed rituximab, abatacept, and methotrexate, it is critical to understand their malignancy treatment options, prognosis as well as the patient’s goals of care. Traditional chemotherapy in certain types of sol...
How do you assess transaminitis in a patient with sarcoidosis with known liver involvement being treated with methotrexate?
This can be fairly tough, as you cannot assess for hepatoxicity from methotrexate in a patient who already has a transaminitis. Hepatic sarcoidosis occurs in 11-80% cases and is often asymptomatic. Some patients may have a transaminitis, elevated alk phos, or liver lesions noted on imaging. Serious ...
Is it okay to use belimumab to treat SLE in a patient who has a history of lymphoma and is on a Bruton's tyrosine kinase inhibitor (such as ibrutinib)?
For patients with ongoing SLE clinical/serologic activity despite ongoing treatment for lymphoma with agents targeting B cell proliferation, it's probably safe to use belimumab if needed in this setting. Thus far, reported experiences and our own using belimumab in patients who have undergone B cell...
Should tuberculosis screening be performed before beginning methotrexate for treatment of rheumatoid arthritis?
While it is not recommended or required to screen for latent TB (LTBI) prior to starting methotrexate, for many patients this may serve as a good opportunity to screen for LTBI, as many patients will go on to require biologic therapy due to incomplete response to methotrexate. There are many limitat...
How do you manage post-menopausal osteoporosis in a patient with stable bone density and no fractures after three years of holiday after giving zoledronic acid?
If the BMD is stable at three years of a post-treatment holiday, I would simply continue the holiday for another 1-2 years. The majority of post-menopausal women were able to achieve 5 years of treatment holiday before BMD dropped to baseline. Repeat the bone density measurement each year or two and...
What are examples of rheumatology quality measures that are both clinically meaningful and can be captured accurately and efficiently?
I can think of the following quality measures that I would recommend to practicing rheumatologists: 1. Screen every new patient with rheumatoid arthritis (RA) for infection with the hepatitis C virus. There are at least a couple of reasons to do this: A) Hep C infection can mimic RA, often with a p...
Is it ever appropriate to initiate a higher initial dose of allopurinol (such as 300mg daily) than is typically recommended in gout patients at low risk of allopurinol hypersensitivity syndrome and severe hyperuricemia?
Usually, allopurinol is started at a dose lower than that and gradually titrated up. This is the best strategy. In a rare instance, allopurinol may be started at 300 mg initial dose - where the patient has tolerated it at this or higher dose previously and is currently non-adherent; or has severe hy...