Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you clinically distinguish between cutaneous lupus with photosensitivity and polymorphic light eruption-like reactions?
Polymorphous light eruption (PMLE) typically occurs at the onset of Spring or Summer when patients have been exposed to light for the first time that season. Because patients' faces are usually not covered up, even in the winter (in non-COVID times), they usually continue to get sun on their faces. ...
What are your thoughts on use of 14-3-3 serum levels in rheumatoid arthritis in conjunction with RF and ACPA?
Until we have a perfect test, it's always worth considering new tests for rheumatoid arthritis (RA). And there are hints that this test may be useful.14-3-3eta is a member of a family of chaperone proteins found in the serum of some patients with RA and other rheumatic diseases.Studies suggest this ...
How do you approach dosage changes of allopurinol as a patient's GFR decreases over time?
Usually, there is no need to adjust the allopurinol dose for a gradual decline in GFR with aging. The renal dose adjustment for allopurinol is for the initial dose of allopurinol to potentially reduce the risk of allopurinol hypersensitivity (Stamp et al., PMID 22488501). To my knowledge, there are ...
Is there a role for regular hepatitis and TB screening in patients on chronic immunosuppressive therapy in the absence of new risk factors or exposures?
Unless there has been an interval introduction of new risk factor for TB or hepatitis B, there is no need to screen annually and baseline testing is adequate.
How would you approach refractory gangrenous Raynaud's secondary to type one cryoglobulins?
Type I cryoglobulins are monoclonal immunoglobulins, and typically occur in the context of a hematologic disorder such as MGUS, multiple myeloma, Waldenstrom macroglobulinemia, or lymphoma. Vascular occlusions due to the cryoglobulins may occur and lead to digital ischemia.The patient should be eval...
Would you consider using teriparatide beyond a cumulative maximum of two years now that the black box warning regarding osteosarcoma has been removed?
This is a very good question. Early studies with PTH compounds for osteoporosis showed you could give it for three years and still have an effect on increasing bone mass. The black box warning was for osteosarcomas that occur in young adults and children, and the black box warning was also for indiv...
How do you approach immunosuppression targeting skin thickening in scleroderma after the initial three years of onset?
I think there is still a role for trial of immunosuppression in the case of a patient who has diffuse skin disease and has signs of progression or lack of improvement even if it is beyond 3 years. If a patient has limited skin distribution (i.e., only sclerodactyly) or the skin has not changed over ...
How do you counsel patients on JAK inhibitors about the risk of venous thromboembolism, MACE, and cancer?
I advise patients that there remain many unanswered questions regarding these side effects that will be resolved with longer term use with these agents. Shared decision-making is critical for these discussions. Data available from current extensions of clinical trials for JAKi, additional risk facto...
What therapies have you had the most success with for calcinosis cutis in dermatomyositis patients?
Treatment of calcinosis cutis is difficult with therapy aimed at the underlying condition. Many of the treatments that have been tried in the literature have been reported in small case reports/series and have had variable success rates. I have tried diltiazem (limited by lightheadedness and fatigue...
When is it necessary to monitor the QTc interval in patients on hydroxychloroquine?
The answer to this question is not straightforward mainly because there are limited data in this area. Hydroxychloroquine and Chloroquine directly affect cardiac repolarization and are associated with QT prolongation. Given this, there is an argument for getting a baseline ECG for patients initiatin...