Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is it ever appropriate to reduce urate lowering therapy dose due to very low urate levels?
In my opinion, there are no known adverse outcomes related to very low serum urate levels. Suspected, but not proven, associations of dementia with sustained hypouricemia, have been used to create an impression that there may be one benefit of avoiding hypouricemia. There are multiple reasons for no...
Would you consider continuing a biologic for difficult to control autoimmune disease in a patient with a recent diagnosis of a surgically curable solid malignancy?
There continues to be relative uncertainty regarding the management of biologic therapy in these patients. As treating physicians, this scenario is not uncommon where a decision to continue or stop a biologic has to be made in face of solid malignancy. A detailed review of individual circumstances t...
How do you decide on initiation of treatment with steroids or immunomodulatory therapy in patients with statin-induced myopathy versus statin-induced autoimmune necrotizing myopathy?
In the setting of limited experience, in patients with statin induced necrotizing polymyositis (HMG-CoA reductase antibody mediated necrotizing myositis), the best approach is typically steroids (prednisone 20mg or so), IViG 2gm/kg every 4 weeks, and potentially CellCept at 2000 to 3000mg per day, w...
How do you approach the management of immunosuppression in patients with lupus nephritis that go on to dialysis?
It depends entirely on their disease status and profile. It is not unusual for patients to have decreased disease activity when they go on HD. If there is still clinical activity though, I maintain them on immune suppressives and prefer mycophenolate mofetil (a major anti-renal transplant rejection ...
When tapering moderate to high doses of long term steroids do you routinely monitor for adrenal insufficiency?
This is always a good question on which to reflect. In general, moderate dosing of steroids (> or = 20 mg prednisone equivalents) for 5 days or less do not need a taper and pose low risk of adrenal suppression, and by extension chronic adrenal insufficiency. Up to date suggests that up to 3 weeks is...
How would you treat corneal melt (in the absence of peripheral arthritis) in rheumatoid arthritis?
Corneal melt is a rare, but serious complication of rheumatoid arthritis. It usually occurs in patients who are sero-positive with active joint disease. A viral infection such as herpes simplex could cause a corneal ulcer that would mimic an immune-mediated melt. It is critical to communicate with t...
How do you treat celiac disease associated inflammatory arthritis refractory to gluten free diet?
There is no good evidence based answer to this great question. In general, if celiac patients have persistent symptoms and exam findings of inflammatory arthritis or enthesitis, I offer non-biologic DMARDs depending on the severity of symptoms. If very mild, we can use hydroxychloroquine and escalat...
What is your approach to evaluation of underlying autoimmune disease in patients with bilateral scleromalacia?
Scleromalacia perforans is an uncommon form of scleritis wherein there is scleral melt in an otherwise white/quiet appearing eye. The most common systemic association for scleromalacia perforans is with long standing rheumatoid arthritis. Other etiologies of scleritis should also be considered: syst...
For patients with scleroderma at high risk of renal crisis, would you feel comfortable giving corticosteroids as pre-medication for rituximab?
I typically will not modify the pre-treatment steroid regimen for Rituxan for scleroderma patients. However, I do assess the patient's risk for scleroderma renal crisis. For example, I consider them high risk if they have early, diffuse scleroderma and particularly if they produce antibodies to RNA ...
Do you recommend EMG/NCS in all patients with clinical findings of carpal tunnel syndrome?
In my experience as a neurophysiologist, a typical Carpal Tunnel Syndrome (with all the classical signs and symptoms) can be diagnosed with high certainty by examination and history alone. My recommendation would be that when the symptoms are mild and the presentation is typical, conservative treatm...