Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach osteoporosis management in a patient who fractures while on denosumab therapy?
This is a scenario that we run into at times and is very difficult with data suggesting a decline in BMD after discontinuation of denosumab as well as data from DATA-Switch trial from 2015 revealed that switching from denosumab to teriparatide resulted in progressive or transient bone loss. I would ...
Would you consider use of belimumab in a patient with SLE with recurrent anterior uveitis who failed other treatment options?
First, uveitis in SLE certainly happens, but it is rare, occurring in less than .5% of patients. So, we have scant evidence on how to treat it beyond case reports (to my knowledge). I have had SLE patients with uveitis (including anterior uveitis), but all responded fortunately to hydroxychloroquine...
Given the "LDL Paradox", in which RA patients with the highest levels of inflammation can have ultra-low levels of LDL (<70), how do you approach initiation of statin therapy in these patients?
Evaluate lipids at the time of remission/low disease activity and if elevated and the patient is a good candidate for statin therapy, initiate a statin using criteria for the general population.
Would you consider use of an oral bisphosphonate (such as alendronate liquid) in a patient with eosinophilic esophagitis?
My general approach to patients with any form of esophagitis for whom bisphosphonate therapy is indicated is to treat with zoledronate. I am not aware of any data that has reviewed the use of a liquid form of a bisphosphonate for patients with esophageal disorders including eosinophilic esophagitis,...
Do you measure drug levels (particularly hydroxychloroquine or mycophenolate) in your lupus patients?
Hydroxychloroquine levels: I absolutely measure hydroxychloroquine (HCQ) drug levels in my patients regularly. As I have mentioned in other answers here and in The Rheumatologist, measuring drug levels has transformed my clinic into a clinic where most of my SLE patients are in remission or have low...
What is your approach to a patient with normal LFTS and high titer auto-antibodies suggestive of autoimmune hepatitis?
Normal LFTs in the setting of high titer liver autoantibodies would still lead me to request a Hepatology consult, even in the setting of a previously defined autoimmune disease, i.e., SLE or Sjogrens. After Hepatology assessment, and if there is a documented rheumatologic autoimmune disease, most o...
Is there any experience of using sarilumab instead of tocilizumab for steroid sparing effect in GCA during national tocilizumab shortage?
This is certainly a very good question, but unfortunately, we don't have an answer. The sarilumab GCA and PMR trials were unfortunately terminated due to the pandemic. I've heard of anecdotal experiences of the use of sarilumab but haven't used it myself (not sure if insurances would approve). Both ...
How would you approach a patient with gastric MALT lymphoma who has CREST syndrome?
The quick answer is, very carefully. To elaborate - I first had to look up what CREST syndrome is - the short answer is limited extent scleroderma, usually the distal upper and lower extremities, but occasionally the head and neck region and most relevant to this question, the esophagus. The literat...
When a patient with a preexisting rheumatic disease and on immunotherapy begins to flare, how do you decide if this is an underlying rheumatic disease activity versus an immunotherapy related adverse event?
If the symptoms/signs are similar to their prior flares of their rheumatic disease, then it is likely a flare. Over 50% of patients with autoimmune diseases flare on immune checkpoint inhibitor therapy if you look at systematic literature reviews of the limited published data. If symptoms are unrela...
In a patient with inflammatory orbital disease without a discrete mass to biopsy and recent bisphosphonate use, how much additional workup would you do if basic labs, urine studies, ANCA serologies, thyroid studies, chest imaging (to r/out sarcoid) are normal, before concluding that the process is likely secondary to bisphosphonate use?
Bisphosphonates are a known but rare cause of orbital inflammation. An intravenously administered bisphosphonate is far more likely to cause this compared to an oral drug. There is usually a close temporal association between taking the medication and developing the inflammation. The diagnosis is on...