Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is a biopsy of either skin or muscle always indicated in the diagnosis of dermatomyositis?
A biopsy of either skin or muscle is not always necessary and the need for each depends on each patient's presentation. A typical history and physical exam, along with MRI or EMG findings, or more importantly, a positive myositis specific antibody can be adequate to make the diagnosis of dermatomyos...
What strategy do you use to determine the appropriate timing to resume osteoporosis therapy after a drug holiday?
A drug holiday (drug sabbatical) is given to reduce the likelihood of an atypical femur fracture. Such fractures have characteristic x-ray appearances and are found from below the lesser trochanter to the supracondylar flare of the distal femur. While the overall incidence of these fractures is low,...
What is your approach to treating dermatomyositis patients with pruritus recalcitrant to oral and topical steroids?
I find this issue of pruritus is best handled by getting better control of the cutaneous inflammatory disease. In this regard, typical DMARD agents (e.g. MTX, mycophenolate, etc) can be helpful in addition to IVIG or even JAK inhibitors. Obviously, all a risk/benefit assessment depends on how debili...
Do you ever consider treatment outside of the peripartum period in a patient with a history of obstetric APS?
I agree with Dr. @Dr. First Last that the patient should be treated with prophylactic low molecular weight heparin and low dose aspirin in any future pregnancies. Dr. Broder makes the very important point that modifiable cardiovascular risk factors should be particularly attended to in persons with ...
What do you view as reasonable alternatives to cyclophosphamide in the treatment of neuropsychiatric lupus?
In general, I very seldom, if ever, rely on cyclophosphamide anymore to treat lupus in general, and much less neuropsychiatric lupus, with few exceptions. As above mentioned, we start off with corticosteroids, followed by a second-line agent, which can be azathioprine, CellCept, Rituxan, etc. We hav...
Do you hold tocilizumab for patients who are diagnosed with Covid and are with mild to moderate symptoms or non-hospitalized?
I generally hold all immune suppressive medications, once a patient is diagnosed with COVID19 to allow for faster clearance of the infection. Inhibition of IL-6 and other immune modulating interventions should be reserved only for hospitalized severely ill patients where the immune system hyper-acti...
How do you approach the use of endothelin receptor antagonists in patients with scleroderma renal crisis and hypertension refractory to maximum ACE inhibition and calcium channel blockers?
There is pathologic evidence of endothelin being increased in the renal biopsies of patients with scleroderma renal crisis. There has been one small prospective open study where endothelin receptor antagonists were used in addition to ACE inhibitors in some refractory patients and compared to histor...
In what circumstances do you pursue labial salivary gland biopsy in an asymptomatic patient with high titer ANA and positive SSA?
I seldom, if ever, suggest a lip biopsy in the work-up of patients with Sjogren's syndrome. It is invasive, and even the histo-pathological interpretation is often open to question. I typically refer patients to an ophthalmologist for a diagnosis of keratoconjunctivitis sicca, if present, and if nec...
Which medications have the lowest risk of tuberculosis reactivation in patients with uncertain tuberculosis history and active rheumatologic disease?
Conventional synthetic DMARDs used in RA are at lower risk for reactivation of latent TB. Steroids do confer some risk of reactivation. The highest risk is the class of biologic DMARDs used to treat RA and many rheumatic diseases with the exception of rituximab.
How do you approach a potential drug holiday in a patient with osteoporosis who has had improvement in BMD after several years of denosumab therapy?
If a patient on denosumab has achieved BMD of the spine and hip that are in the high osteopenia range or normal BMDs (T score above -1), and the patient has not fractured and is not on glucocorticoids or hormone depleting agents for breast or prostate cancer, can have denosumab stopped. However, at ...