Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach prophylaxis against glucocorticoid-induced osteoporosis in patients with end-stage renal disease on dialysis?
Treating patients with end-stage renal disease on glucocorticoids to prevent bone loss is a challenge. A patient with end-stage renal disease cannot be treated with bisphosphonates. However, denosumab the RANKL antibody has no restrictions regarding renal disease. So my suggestion is to treat a pati...
How would you approach definitive treatment of intermediate-risk prostate cancer with baseline severe (AUA >25) urinary dysfunction and severe rheumatoid arthritis?
This case presented has a number of possible variables. First, does intermediate risk in this case, Gleason 7, 3+4, or 4+3 or some other set of variables making the case intermediate risk? That might change management in terms of use of ADT use, etc. However, the question's focus appears to ask for ...
Should we recommend the COVID-19 booster vaccine to patients who had a DVT or any other complications such as hemolytic anemia or thrombocytopenia from prior vaccine doses?
There are a few case reports of VTE following COVID-19 vaccinations (approximately 10 based on my PubMed review today). However, VTE has a high incidence of 0.1% in the general population and much higher after age 45 (Mary Cushman, PMID 17433897), so determining a causal relationship between the vac...
Is there a role for immunosuppression in patients with triple positive antiphospholipid antibodies who do not meet the clinical criteria for APS?
Currently, there are no “clinical” nor “diagnostic” criteria for antiphospholipid syndrome (APS). I suspect your question refers to patients not meeting the Sapporo APS “classification criteria.”There are two primary ways that patients with triple-positive antiphospholipid antibodies (aPLs: anticard...
Do you screen for HLA-B*5801 prior to starting allopurinol in patients of backgrounds other than Asian or African-American?
The guidelines now recommend checking for the presence of the HLA-B*5801 gene only in Asians and African-Americans. However, in our clinic, we are checking for the presence of this gene on everybody who becomes a candidate to receive allopurinol, partly due to the fact that we are doing a study. Int...
How do you diagnose and treat patients who develop uveitis while on bisphosphonate therapy for osteoporosis?
Ocular inflammation, usually anterior uveitis, can occur as a consequence of bisphosphonate therapy. Virtually always, the bisphosphonate is one that is given intravenously and the ocular inflammation begins a day or two after the treatment. Furthermore, the inflammation is generally self-limited; i...
What is your steroid-sparing agent of choice to treat GCA given the current tocilizumab shortage?
If at all possible, I continue to use tocilizumab as a glucocorticoid sparing agent for patients with giant cell arteritis. Given the results of the GIACTA trial, the Villiger trial, and lots of observational data, it is clear that tocilizumab provides efficacy in terms of reducing risk of relapse a...
What are your recommendations regarding methotrexate usage in patients with persistent chest CT changes post COVID pneumonia?
With the raging pandemic and the steady stream of post-COVID inflammatory/fibrotic patients, we are bound to encounter patients with such abnormalities who are on potentially pneumotoxic drugs (or need initiation).With minimal concrete data, any recommendation is purely based on experience.Methotrex...
What particular pre-operative considerations should we consider for SLE patients undergoing elective surgery?
Our guidance in the perioperative management of systemic lupus erythematosus (SLE) patients is essential. A 2016 study showed they are at a much higher risk for falls, thrombosis, acute kidney injury, and infections compared to patients with osteoarthritis (Roberts). This increased risk is even pres...
Do you recommend COVID vaccination in patients with antiphospholipid antibody positivity or other prothrombotic states not on anti-coagulation?
There are hypothetical reasons that the COVID-19 vaccine might increase thrombophilia in individuals with APS/APLAs. However, the only controlled study I could find, Absence of hypercoagulability after nCoV-19 vaccination: An observational pilot study by Campello et al., PMID 34246010 did not show a...