Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is the role for angiography in the workup of digital ischemia?
Digital ischemia is an especially serious complication in patients with rheumatic disease, particularly scleroderma but can also be a feature of lupus, vasculitis (ANCA associated, PAN), antiphospholipid syndrome, and rheumatoid vasculitis, among others.The presence of digital pain with permanent/pe...
Do you routinely obtain a chest x-ray prior to initiating anti-TNF or other biologic therapy?
I don't routinely order a chest x-ray in patients with negative quantiferon (or other latent TB testing such as the T-spot) before starting biologics. The chest x-ray is much less specific for latent TB, particularly in the United States where TB is not endemic. Patients may have granulomas or other...
What is your preferred approach for patients with anti-phospholipid syndrome with recurrent thrombosis on coumadin and LMWH?
This is a difficult condition to manage and personalized approach/risk stratification is key. There are several potential considerations:Warfarin therapy could be intensified, anti-platelet agents could be considered (although not in combination with LMWH).For patients with an underlying autoimmune ...
How would you approach treatment for fulminant RA-associated ILD?
Even though this hypothetical patient has tolerated methotrexate (MTX), I would probably stop it since MTX can directly scar lung parenchyma and continuation of it may confuse the clinical picture. The data for adverse lung toxicity with TNFi drugs is less clear, so I would consider maintaining it. ...
In patients who develop a VTE, what conditions do you consider as persistent, provoking risk factors, and at what point are they controlled enough to stop anticoagulation?
Not a lot of controlled trials that address each situation so we rely on expert consensus and judgement, and more importantly, balancing the risk of hemorrhage vs thrombosis. ASH guidelines define chronic persistent risk factors as 1) Active cancer (e.g., ongoing chemotherapy; recurrent or progressi...
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...