Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you pursue cholestyramine washout in a patient on leflunomide for RA who is experiencing worsening necrotic dental infection secondary to pseudomonas?
I would pursue a BRIEF washout of leflunomide... a single day of cholestyramine, which will reduce blood levels 50%. This was used in the phase 3 trials with good results, e.g., a decrease in blood levels and rapid resolution of related adverse events. There is not a need for the 5 days of washout, ...
How do you decide whether to continue hydroxychloroquine in a young patient who develops subretinal neovascularization with no other risk factors?
Hydroxychloroquine (HCQ), an anti-inflammatory and immunomodulatory agent, is used to treat autoimmune diseases (rheumatoid arthritis, lupus, Sjogren’s disease, etc.) and malarial prophylaxis. Vision problems can ensue resulting from these deleterious irreversible effects of HCQ on retina if the cum...
Do you reduce the dose of hydroxychloroquine in patients with skin graying if they are not particularly bothered by this side effect?
1. I would check a trough whole blood HCQ level. Nathalie Costedoat-Chalumeau and her colleagues found higher levels in patients who developed skin pigmentation (Jallouli et al., PMID 23824340), but actual levels were not reported. Petri et al also showed that levels above 1200 ng/mL were associated...
What were your top takeaways in SLE from ACR Convergence 2025?
My takeaways were excitement about obintuzumab being approved, the question as to what level of proteinuria justifies biopsy, different new biomarkers regarding lupus nephritis, plus the ongoing chaos regarding CART and its spin-offs.
How do you screen rheumatoid arthritis patients for lung disease (modality, frequency, patient selection)?
Theoretically, we are supposed to screen these patients obtaining a baseline chest X-ray before starting DMARD therapy. As I remember, these guidelines were formulated when MTX was still blamed for MTX lung disease although presently, even the presence of underlying ILD is not necessarily a contrain...
Do you start bisphosphonates after tapering off menopausal hormone therapy to prevent the rapid decline of bone mineral density?
Women lose one T-score unit (10-12%) of bone mass on average during menopause. Estrogen, as a part of menopausal hormone therapy (MHT), is approved by the FDA to prevent osteoporosis, but not for its treatment. Upon MHT discontinuation, women will experience a period of rapid bone loss, for which st...
Do you pursue a malignancy workup beyond age-appropriate malignancy screening in patients with antibody negative necrotizing myopathy?
This is a great question that speaks to the nuanced (and still-being-elucidated) association between malignancy and the increasingly better sub-divided different autoimmune myositis subtypes:While anti-SRP and anti-HMGCR are the two myositis-specific antibodies (MSA) most closely associated with imm...
What are the clinical prompts that lead you to consider deprescribing bisphosphonate therapy in older adults with osteoporosis?
As a Geriatrician, the essence of my practice is to determine, on regular review (reconciliation), whether an older adult’s medication is appropriate to continue or continue at the same dosing on the basis of physiology, pathology, and/or risk modification. We know well today that medications for os...
When do you consider certolizumab for pregnant women with antiphospholipid syndrome with positive lupus anticoagulant?
Certolizumab is a TNF-α antagonist with minimal or no transfer across the placenta. It was evaluated in the phase 2, open-label IMPACT (Improve Pregnancy in APS with Certolizumab Therapy) trial to prevent placenta-mediated adverse outcomes in pregnant patients with antiphospholipid antibody syndrome...
How often do you draw screening ANAs for discoid lupus?
Because a positive ANA is associated with an increased risk of progression to SLE in patients with discoid lupus, I routinely check an ANA at the initial visit in virtually all patients. If negative, I repeat it only if new symptoms concerning systemic involvement arise (e.g., joint pain, cytopenias...