Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach relapsing ANCA-associated vasculitis in a patient who has already undergone kidney transplant?
In a very individualized way (What has the patient been treated with before? What is the current transplant immunosuppression? etc.) and in conjunction with a transplant nephrologist. One could imagine re-induction with rituximab would work in many cases but specifics about each individual case will...
When do you consider DMARD therapy in patients with persistent oligoarticular JIA who continue to flare in adulthood?
Hey there! I think the question you're asking is when to think about moving past NSAIDs or corticosteroid injections and towards DMARDs? If that isn't your question, please clarify. If it is your question, then my answer would be if you're thinking about DMARDs, you should start DMARDs. I don't cons...
When do you reach for tacrolimus in patients with myositis?
It's a really great clinical question but, unfortunately, driven just as much by anecdotal practice as by objective data. Calcineurin inhibitors such as tacrolimus (Tac) and cyclosporine (Csp) work by mechanisms that ultimately lead to a decrease in T cell activation. As CD8+ T-cells play a major pa...
What is your experience with using extended release intra-articular steroid preparations, such as Zilretta in patients with osteoarthritis?
Intra-articular glucocorticoids have been used for decades to treat painful knee osteoarthritis. In the past, steroid preparations of relatively insoluble crystals such as triamcinolone hexacetonide were used with the intention of prolonging the duration of intraarticular action. Although the retent...
Have you had experience using the new Echolight technology to measure bone density?
I have heard of it but as of yet have not had experience with it. If I had access to it I would use it and compare it to standard DEXA. Good luck!
How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?
I would refer to the following article that provides the most up-to-date definitions (including the definitions for low-level antibodies) and risk stratification tools including APL-S and GAPSS that are developed for people with autoimmune conditions. The article also discusses the levels of evidenc...
Would you avoid the entire class of bisphosphonates if a patient develops an allergic reaction, or would you consider the use of an alternative bisphosphonate?
Interesting question and an important clinical issue. If the adverse event or side effect was not serious, I would try another bisphosphonate. If it occurred on alendronate, I would try a low dose or risedronate and monitor. If the side effect occurred from the IV infusion, I also would try a low do...
Is there a role for IVIG in the treatment of active morphea refractory to immunosuppressive agents?
While the exact mechanism of action remains unclear, IVIg therapy has demonstrated good efficacy in several rheumatic conditions including Inflammatory myositis, refractory cutaneous lupus, and also in sclerotic conditions like Systemic sclerosis where it is believed to work by increasing regulatory...
What is your approach to workup for an underlying disorder in a patient with bilateral hip avascular necrosis?
The approach to assessing hip osteonecrosis is to address the potential causes: Is there a history of antecedent trauma? Is there a family history of osteonecrosis? Is there a history of significant alcohol use? Is there a history of recent corticosteroid use? Is there a history of pancreatitis? Is ...
Does romosozumab need to be followed immediately by an anti-resorptive agent to preserve BMD gains, or could you consider a drug holiday?
A drug holiday after romosozumab is not appropriate, since we know from the phase 2 studies that BMD rapidly declines if it is not followed by antiresorptive therapy. I suggest starting an antiresorptive agent 1 month after the last dose of romosozumab, or soon thereafter. Studies show that Dmab aft...