Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you find trabecular bone score (TBS) useful in patients with a history of ankylosing spondylitis when screening for vertebral fracture risk?
Yes, the ankylosing spondylitis population is a group that could benefit from the evaluation of TBS. DXA-based spine bone mineral density is artificially elevated in the setting of ankylosing spondylitis (due to osteosclerotic artifact from underlying disease), and therefore, spine bone density is a...
Would you consider using LDRT for joint pain/arthritis caused by aromatase inhibitors as a means to keep patients on therapy?
I would try this. I think there is an inflammatory component to this, and the subjective complaints appear to mimic OA. However, I do think this would be a wonderful group of patients to try this on. They are probably already comfortable with radiation, the achiness/discomfort from ET is real and we...
What is the preferred osteoporosis therapy after completing teriparatide in a young woman planning pregnancy within the next year?
It would be helpful to know the T-scores of the spine and femoral neck. I also like to have the bone remodeling markers. My recommendation would be adequate calcium intake of 1000 mg daily, preferably from diet, and 4000 IUs of vitamin D daily, not only to help preserve bone health, but vitamin D al...
How do you determine whether to add abatacept or rituximab to the treatment regimen in patients with mild RA-ILD on methotrexate?
I think of many agents before rituxan for RA ILD: all in various stages of being studied MMF, Orencia/abatacept, Tocli/actemra, and even JAK inhibitors xeljanz/rinvoq. Generally, if I treat and control the joints, the lungs stabilize. 10-20% run independently from joints or extra-articular ILD witho...
How would you approach management of a young woman referred for isolated anterior uveitis (now resolved), in the absence of systemic manifestations or end-organ involvement, but with serologies notable for strongly positive PR3 (negative c-ANCA)?
This is a challenging case. While up to 50% of anterior uveitis are idiopathic, and uveitis is relatively uncommon in GPA (<5-10%, episcleritis and scleritis are the most common ocular manifestations. The PR3 antibody is quite specific. Therefore, I would have a high index of suspicion that the uvei...
Do you prescribe hydroxychloroquine to patients who are on other medications that can prolong the QT interval?
First, I'll remind everyone that before COVID-19, case reports of QT-prolongation-associated arrhythmias were rare. It wasn't until COVID that we all at once saw cases with the caveats that these were in patients treated with higher doses of HCQ, commonly loading doses of 800 mg daily, plus COVID-1...
What is your algorithm for transitioning a patient with chronic noninfectious posterior uveitis from corticosteroids to immunosuppressive therapy?
There are some forms of noninfectious posterior/panuveitis where it is known from the time of uveitis diagnosis that steroid-sparing immunosuppression (IMT) will be needed. For example, in birdshot retinochoroiditis or serpiginous choroidopathy, IMT is often initiated in concert with oral corticoste...
In which Sjogren's patients do you prioritize systemic treatment strategies at time of diagnosis?
Answering this question would really depend on what exact type of patient you are dealing with. You may consider initiating oral DMARDs such as hydroxychloroquine, methotrexate, or azathioprine for patients with inflammatory arthropathy or significant autoimmune rashes. More aggressive therapy would...
Are there clinical, laboratory, or imaging features that can help distinguish primary Sjögren’s syndrome from secondary Sjögren’s in patients with overlapping inflammatory arthritis or positive rheumatoid factor?
Such a good query. I don't really know, as associated SjD has been understudied. In my experience, associated Sjogren's does not look that different from Sjogren's alone. We have seen high ocular staining scores and markedly reduced unstimulated salivary flow in associated SjD (SLE, RA). In SjD, the...
In a patient with high +SSA antibodies and distal renal tubular acidosis (RTA), but without sicca symptoms or other systemic features of Sjogren's, should immunomodulatory therapy with hydroxychloroquine or azathioprine be considered in an effort to reduce subclinical tubular inflammation and prevent progression of renal disease?
Renal disease can occur as an initial manifestation in the absence of sicca in SjÓ§gren’s disease (SjD) patients (Goules et al., PMID 31464673). This is important to realize for other systemic manifestations of SjD (e.g., cystic lung disease, tubulointerstitial nephritis, radiographic nephrocalcino...