Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In the absence of lung disease, do you prefer methotrexate or mycophenolate mofetil in the initial treatment of cutaneous-only manifestations in systemic sclerosis?
I typically will use mycophenolate if I think the patient needs "skin only" treatment. This recommendation is based on my personal experience, retrospective and observational data, and data that can be gained from other clinical trials (SLS2 for example). If the patient has prominent joint disease, ...
What features help distinguish thyroid myopathy from immune checkpoint inhibitor-associated myopathy?
Immune checkpoint inhibitors (ICIs) can cause myositis (ICI-myositis). Since ICIs can also induce hypothyroidism, myopathy secondary from hypothyroidism can also be associated with ICI therapy. Different from thyroid myopathy, patients with ICI-myositis barely have myoedema or muscle pseudohypertrop...
How do you treat lupus-associated small fiber neuropathy?
Treatment of small fiber neuropathy associated with SLE consists mainly of symptomatic treatment for neuropathic pain and, if present, autonomic symptoms. Commonly used treatments for neuropathic pain include topical agents such as lidocaine, tricyclic antidepressants such as amitriptyline or nortri...
Are there any known contraindications for IL-23 use in patients with psoriatic arthritis and CKD or ESRD?
There are no contraindications in the use of IL-23 inhibitors in the treatment of psoriatic arthritis. The package insert suggests no dosage adjustments for CKD. Clearance of a monoclonal ab is through degradation to small peptides and amino acids in a fashion similar to endogenous IgG. My only conc...
What are your recommendations for a patient with metastatic non-mutated lung adenocarcinoma who previously had headaches responsive to prednisone but with negative temporal artery biopsy for GCA?
GCA is often a challenging diagnosis to make in the absence of objective findings of halo sign, pathologic evidence of vasculitis, or large vessel vasculitis on imaging. Headache of any type will often respond to prednisone so the first step, in this case, is to determine if the patient truly has GC...
What is the role of synovectomy in the diagnosis and management of patients with inflammatory arthritis?
The role of surgical synovectomy for the diagnosis of patients with inflammatory arthritis has shrunk dramatically with the ability to perform less invasive ultrasound-guided synovial biopsies. Improved treatments for inflammatory arthritis have decreased the need for surgical synovectomies but shou...
How do you use hydroxychloroquine in patients with lupus nephritis on hemodialysis or peritoneal dialysis?
After starting dialysis, other lupus manifestations frequently become clinically inactive. However, there is still a subset of patients who have clinical or serologic activity. Prior studies have shown that < 6% of lupus patients remain clinically active 5 years after starting dialysis, < 25% remain...
What has been your experience using apremilast to treat mild to moderate psoriatic arthritis not controlled with NSAIDs?
Overall, my experience has been good with apremilast when the correct patient is targeted for therapy. The best patient generally falls into a niche of milder disease. Mild to moderate psoriasis and milder and less aggressive MSK manifestations. Patients need to realize that they are trading speed o...
Do you avoid PTH/PTHrP analogs in patients with recurrent/severe CPPD?
I assume Dr. @Dr. First Last meant PTH-related bone-building drugs, not bisphosphonates, in his answer. I agree that I would use these drugs if needed in someone with CPPD disease, but I have not come across the scenario outlined in the question and am not aware of any data on the use of these drugs...
How do you manage drug-induced thrombocytopenia when the implicated drug is essential?
I feel obliged to answer this one as a question of medical sociology as much as a direct medical question, because "essentialness" is nearly always in the eye of the beholder, and I have not personally been in the position of the hematologist who has to confront this question with an interventional ...