Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to evaluation of underlying autoimmune disease in patients with bilateral scleromalacia?
Scleromalacia perforans is an uncommon form of scleritis wherein there is scleral melt in an otherwise white/quiet appearing eye. The most common systemic association for scleromalacia perforans is with long standing rheumatoid arthritis. Other etiologies of scleritis should also be considered: syst...
For patients with scleroderma at high risk of renal crisis, would you feel comfortable giving corticosteroids as pre-medication for rituximab?
I typically will not modify the pre-treatment steroid regimen for Rituxan for scleroderma patients. However, I do assess the patient's risk for scleroderma renal crisis. For example, I consider them high risk if they have early, diffuse scleroderma and particularly if they produce antibodies to RNA ...
Do you recommend EMG/NCS in all patients with clinical findings of carpal tunnel syndrome?
In my experience as a neurophysiologist, a typical Carpal Tunnel Syndrome (with all the classical signs and symptoms) can be diagnosed with high certainty by examination and history alone. My recommendation would be that when the symptoms are mild and the presentation is typical, conservative treatm...
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...