Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach a patient with gastric MALT lymphoma who has CREST syndrome?
The quick answer is, very carefully. To elaborate - I first had to look up what CREST syndrome is - the short answer is limited extent scleroderma, usually the distal upper and lower extremities, but occasionally the head and neck region and most relevant to this question, the esophagus. The literat...
When a patient with a preexisting rheumatic disease and on immunotherapy begins to flare, how do you decide if this is an underlying rheumatic disease activity versus an immunotherapy related adverse event?
If the symptoms/signs are similar to their prior flares of their rheumatic disease, then it is likely a flare. Over 50% of patients with autoimmune diseases flare on immune checkpoint inhibitor therapy if you look at systematic literature reviews of the limited published data. If symptoms are unrela...
In a patient with inflammatory orbital disease without a discrete mass to biopsy and recent bisphosphonate use, how much additional workup would you do if basic labs, urine studies, ANCA serologies, thyroid studies, chest imaging (to r/out sarcoid) are normal, before concluding that the process is likely secondary to bisphosphonate use?
Bisphosphonates are a known but rare cause of orbital inflammation. An intravenously administered bisphosphonate is far more likely to cause this compared to an oral drug. There is usually a close temporal association between taking the medication and developing the inflammation. The diagnosis is on...
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...