Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you offer palliative radiation for painful bone metastases in a patient with scleroderma?
Yes, I have treated a breast cancer patient before who had scleroderma and she really wanted to avoid mastectomy. Maybe I was just lucky, but no major skin reaction. Maybe less than average even. Her disease was not active at the time. For bone met palliation, I would use higher energy like 15X for ...
How do you counsel patients regarding the cardiovascular and cancer risks associated with tofacitinib?
In my experience, trying to discuss incidence rates and hazard ratios with patients is usually met with a response such as, “So what does this mean for me?” Translating the incidence rates into the number needed to harm (NNH) provides objective numbers which are easier for them to understand. Treati...
Do you still plan to offer tofacitinib to RA patients over 65 if they have one or more additional CV risk factors?
I would consider offering tofacitinib (or another JAK inhibitor) to patients over 65 with an additional CV risk factor, but only as a last resort after all other options have been exhausted.
How do you treat patients with sarcoid who have persistent symptoms after an initial 6 week course of corticosteroids?
The answer to this question depends on what organ(s) you are treating and how severe the manifestation(s) is/are because you must balance the risk of the treatment itself, and the risk of flare with an aggressive steroid taper. 6 weeks of steroids is not appropriate for cardiac sarcoidosis that over...
What is the difference between Multisystem Inflammatory Syndrome in Adults (MIS-A) and MAS/HLH?
Macrophage activation syndrome (MAS)/hemophagocytic lymphohistiocytosis (HLH) are cytokine storm syndromes (CSS) associated with various infections, rheumatic conditions, and hematologic malignancies (among other etiologies). Multi-system inflammatory syndrome in adults (MIS-A) is a discrete entity ...
Would you anticoagulate recurrent venous thromboembolism in a patient with Ehlers Danlos syndrome?
Yes, but know the hx of bleeding. Would use low dose Coumadin one 1.5 to 2, have good antidotes for Coumadin.
In what patients would you consider adjunctive IVIG for Sjogren's-related neuropathy?
Would consider IVIG in Sjogren's with disabling neuropathy not responding to other treatments (steroids/DMARDs, mycophenolate), in sensory ataxic neuronopathy/dorsal root ganglionitis, and immune-mediated (CIDP).Co-manage with neuro-immunologist, if an option.Literature is a small case series and ca...
What is the preferred approach to treating poorly-controlled RA in the setting of active hepatitis B undergoing anti-viral therapy?
I typically refer these patients to GI hepatology. Once GI hepatology formulates a treatment plan for the hepatitis B, I ask them if they are comfortable with a proposed RA treatment plan from a liver standpoint. I do this mainly to have a discussed treatment plan officially documented, and also for...
Do you escalate treatment for reactive lymphadenopathy in an otherwise stable and asymptomatic patient with lupus?
With today's medical evidence, I do not treat my patients' lymphadenopathy (LAD) alone. However, lupus-reactive LAD tends to occur with active disease. I am a big believer in the treatment goal of "remission (without steroids); if remission is unachievable, then low disease activity using the safest...
How long do you continue hydroxychloroquine in pediatric patients with quiescent lupus?
Indefinitely, if no GI toxicity and annual ophthalmologic screens do not reveal retinal toxicity. Hydroxychloroquine is beneficial at preventing disease flare, and even delaying lupus onset in those who tested positive for anti-nuclear antibody (ANA). The benefit: risk ratio favors prolonged use.