Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Which medications have the lowest risk of tuberculosis reactivation in patients with uncertain tuberculosis history and active rheumatologic disease?
Conventional synthetic DMARDs used in RA are at lower risk for reactivation of latent TB. Steroids do confer some risk of reactivation. The highest risk is the class of biologic DMARDs used to treat RA and many rheumatic diseases with the exception of rituximab.
How do you approach a potential drug holiday in a patient with osteoporosis who has had improvement in BMD after several years of denosumab therapy?
If a patient on denosumab has achieved BMD of the spine and hip that are in the high osteopenia range or normal BMDs (T score above -1), and the patient has not fractured and is not on glucocorticoids or hormone depleting agents for breast or prostate cancer, can have denosumab stopped. However, at ...
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...