Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there a role for starting an anabolic agent in a patient that developed an atypical femoral fracture while on denosumab sooner than 6 months after the last denosumab dose?
The biology of an AFF is still being elucidated. However, there are many aspects of an AFF that are similar to a "stress fracture" in that there is a combination of osteoid and cartilage that does not fully mineralize. Fracture healing goes through a cartilaginous phase, followed by mineralization w...
What is your approach to treating severe manifestations of neuropsychiatric SLE in the setting of concomitant infection?
This is a scenario that most rheumatologists will face during their careers, and it always makes us nervous. We ask ourselves your exact question as we decide upon management.First, I cannot let this question go without making a statement about the term "neuropsychiatric SLE." I propose that this sh...
Is there a role for measuring serum mycophenolate mofetil levels (or its active metabolite) in the management of lupus nephritis?
I check MMF levels in 2 different scenarios: It helps improve adherence. If levels are undetectable, this provided an opportunity to discuss adherence with patients and to identify barriers to taking MMF more regularly without skipping doses. For patients with CKD/ESRD who are on low MMF doses and ...
Would you consider single agent TKI for patient with metastatic renal cell carcinoma who developed biopsy proven giant cell arteritis days after starting immunotherapy?
Clinicians are not infrequently in situations where we need to help guide patients along a decision pathway for which we have little data. The vasculitis in this patient obviously was a pre-existing condition. The first question I would ask is does the patient's RCC need treatment now? If favorable ...
How do you approach infused prostacyclin therapy for critical digital ischemia?
This is a great question! Critical digital ischemia (CDI) associated with Raynaud phenomenon (RP) requires urgent measures to prevent digit loss. While, thankfully this is not very common, we come across it often enough in patients with structural vascular disease (occlusive vasculopathy) superimpos...
What is your differential for a patient presenting with multiple digits affected by flexor tenosynovitis, dupuytren's, and no evidence of peripheral inflammatory arthritis?
Other than idiopathic Dupuytren's and recreational or occupational flexor tenosynovitis, I would look for underlying thyroid disorders that can induce trigger finger with some palmar fascia and tendon thickening, and also diabetic cheiroarthropathy. There are several musculoskeletal complications se...
What indicators do you use to identify patients with CTD-ILD who do not have potential to improve from continued immunosuppressive therapy?
This is an interesting question. We need to clarify what this phrase means "who do not have potential to improve". It may be easier to identify patients who may benefit from therapy.ILD physicians work under the motto, 'stability is success'. Thus, improvement may mean 'did not deteriorate'. Minimal...
How do you approach treatment of vasculitis in a sickle cell disease patient?
Will highly depend on the vasculitis type and the acuity of the situation. For ANCA vasculitis, approaches based on rituximab and low glucocorticoid doses might be attractive (granted not severe disease, e.g. RPGN, DAH which should require pulse glucocorticoids). For large vessel vasculitis, a si...
Is it ever reasonable to switch to a different TNFi as opposed to switching to an agent in a different class in a case of TNFi induced lupus or psoriasis?
This is a very interesting question where the answer continues to evolve. I would also like to answer the question separately. Both Psoriatic skin lesions and lupus or lupus-like conditions can be induced by anti-TNF-alpha therapy. The pathogenesis may involve changes in cytokine balance.Regarding P...
How long would you treat with antimycobacterials before starting biologic DMARD in a patient with latent TB and active rheumatoid arthritis?
This is a common question rheumatologists ask their ID colleagues. Given the diversity of patient presentations, though, there isn't a blanket answer. One reason there's no blanket answer is because it is so hard to study LTBI risks, due to infrequent conversion to active TB, which is a fortunate th...