Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there a role for medications, beyond treatment for concomitant psychiatric disorders, in the management of pediatric amplified musculoskeletal pain syndrome?
Having been trained by Dr. David Dan Sherry, my answer would be, "no". Using medicines might make the clinician or the patient/family feel better, but they do not work. Medicinal therapy also takes the focus off the 2 required pathways for optimal treatment, namely aerobic exercise (lots of it) and ...
Do you recommend routine genetic screening (i.e., periodic fever panel) in a pediatric patient where you strongly suspect a periodic fever syndrome?
Genetic testing for periodic fever syndromes is potentially very informative and rather inexpensive. My approach is to generally obtain genetic testing in patients with suspected periodic fever syndromes as part of their initial laboratory evaluation with the exception of typical cases of PFAPA (Per...
How do you manage anti-Mi-2 positive dermatomyositis with predominantly cutaneous manifestations?
Anti-Mi-2 usually has a good prognosis. So, if patients only have skin manifestations with anti-Mi-2, I would give methotrexate either without steroids (if symptoms are currently tolerable and the patient can wait for a few months) or with steroids (if intolerable symptoms). If this fails, I would g...
How do you approach urate-lowering therapy in patients with advanced chronic kidney disease?
I lower uric acid independent of GFR. There is little evidence to support limiting uric acid-lowering therapy. This misinformation came out due to combining fears that the incidence of allopurinol reactions would increase in patients with renal insufficiency. Allergic reactions are related to exposu...
How do you approach the use of bisphosphonates in reproductive-aged women?
This is an extremely difficult situation. I think it would be better to change this question to a discussion of a woman of childbearing potential since a woman of reproductive age with osteoporosis could have hormone failure and therefore is not of childbearing potential per se. A woman with celiac ...
Is there a role for immunosuppression in addition to standard PAH therapy in the management of pulmonary hypertension associated with primary Sjogrens syndrome?
In short: maybe. Pulmonary hypertension is quite uncommon in Sjogren’s. When I find it, I look for other causes of pulmonary hypertension, especially ILD, and for systemic sclerosis. I also consider other potential indications for immunosuppressive therapy such as inflammatory joint pain. There is, ...
Do you feel comfortable using azathioprine for dermatomyositis in patients with cirrhosis?
Azathioprine can cause liver damage, albeit this is a rare complication and usually asymptomatic. Therefore, I would probably avoid it in cases of liver cirrhosis and try other medications, like mycophenolate, IVIG, tofactinib. In either case, I would consult at the same time with the patient's hepa...
At what point do you recommend muscle biopsy in the workup for myositis?
Muscle biopsy is generally recommended and useful in most cases of suspected inflammatory/immune myopathy; accurate pathologic diagnosis is imperative for prognostication, identification of comorbid conditions (e.g., cancer, interstitial lung disease, arthritis, etc.), and treatment decisions. Histo...
What is your approach to treating tophaceous gout in patients whose uric acid is below 5 prior to initiating uric acid lowering therapy?
The finding of tophi is associated with elevated total body uric acid. If this is a true serum uric acid, it is conceivable the patient is a high urine excretor to explain the low serum uric acid. Checking uric acid excretion could elucidate this. Alternatively, low serum uric acid level could be a ...
Would you have concerns starting an anti-TNF in RA patients with history of ITP/chronic idiopathic thrombocytopenia?
Clinically significant thrombocytopenia is a rare but documented side effect of tumor necrosis factor inhibitors. If an alternate class of medication for this patient can be found, that would be the safest choice. If there is no alternative, then would follow platelets counts frequently.