Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
How would you manage a patient with strongly suspected Lyme arthritis and negative bacterial synovial fluid cultures who was started on empiric antibiotics against typical bacterial pathogens arthritis before arthrocentesis and collection of cultures?
In a patient with a high clinical suspicion for Lyme arthritis who has negative synovial fluid bacterial cultures after receiving empiric antibiotics for presumed septic arthritis, management should be guided by clinical probability rather than the culture results. Antibiotics given before arthrocen...
How does the presence of myositis alter your interpretation of cardiac enzymes when evaluating acute chest pain?
Troponin T and CK-MB are not reliable for cardiac issues in myositis as regenerating muscles produce these enzymes. This is especially true if the patient has an active disease with weakness and CK elevation. Troponin I is not much affected by muscle enzymes and should be used as a parameter to eval...
Do you use bone turnover markers to assess medical adherence in patients treated for osteoporosis?
I find the bone remodeling markers very helpful. First and foremost, I want to be sure that if I am going to put a patient on an antiresorptive medication that the patient has evidence for high bone turnover over i.e., increased osteoclastic activity. If the bone remodeling markers for both bone for...
How, if at all, do you incorporate techniques such as mindfulness into your discussions with patients who have chronic pain, particularly if they are on long-term opioids?
I do use the Oregon Pain Management website with my chronic pain patients, and if they select the mindfulness tile, I go over this with them and refer them to our embedded behavioral health provider. I also teach the "square breathing" technique quite often to anxious patients with or without pain, ...
Would you consider a shorter course of Romosozumab (3 months) followed by maintenance therapy given recent evidence that it is noninferior to 12 months of therapy for treatment of severe osteoporosis?
A recent publication led by Leder et al (Lancet Diabetes Endocrinol 2026;14: 216–22) demonstrated that a brief 3-month course of romosozumab followed by denosumab was noninferior to a full 12-month course of romosozumab given in the standard manner. This is consistent with earlier (nonrandomized) ob...
What is your approach to the diagnostic workup of small fiber neuropathy in patients with known rheumatic disease?
Small fiber sensory neuropathy (SFN), in general, including in patients with rheumatic diseases, should be suspected based on symptoms (positive more than negative sensory symptoms) and ideally confirmed by clinical examination showing altered temperature and/or pain/pinprick perception in the limbs...
How do you approach adjusting insulin pump settings in patients who have received intra-articular corticosteroid injections?
Managing steroid-induced hyperglycemia in patients with diabetes has always been a difficult problem, and guidelines are hard to come by. Glucocorticoids cause increased insulin resistance and an increased need for insulin. The steroid effect on glucose is greater in the post-prandial state than the...
When do you consider testing autoimmune antibodies for axonal polyneuropathies without clear etiology?
Dr. @Dr. First Last gave an excellent summary of the clinical red flags that should trigger antibody testing in polyneuropathies. I would like to highlight that not all antibodies are pathogenic or cause the same phenotypes/clinical syndromes; therefore, I would like to break it down by antibody gro...
What is your approach to refractory oral ulcers in SLE?
Prior to availability of apremilast for psoriatic disease and Behcet disease (which can be effective if a case can be made for the patient accessing this), I found thalidomide to be very effective for this.