Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
Do you avoid PTH/PTHrP analogs in patients with recurrent/severe CPPD?
I assume Dr. @Dr. First Last meant PTH-related bone-building drugs, not bisphosphonates, in his answer. I agree that I would use these drugs if needed in someone with CPPD disease, but I have not come across the scenario outlined in the question and am not aware of any data on the use of these drugs...
How do you manage drug-induced thrombocytopenia when the implicated drug is essential?
I feel obliged to answer this one as a question of medical sociology as much as a direct medical question, because "essentialness" is nearly always in the eye of the beholder, and I have not personally been in the position of the hematologist who has to confront this question with an interventional ...
What is the differential for a patient with unilateral arm swelling, MRI with muscle edema, and markedly elevated CPK?
The differential for focal myositis is broad, although many times no obvious etiology is revealed and in that case, it is considered to be idiopathic. Etiologies that need to be ruled out are: malignancy (usually confirmed by biopsy), infections (like mycobacteria, viruses, fungi; usually will have ...
What is the role of x-ray of the cervical or lumbar spine in patients presenting with radicular symptoms?
I agree that X-rays are useless the vast majority of the time. You can of course pick up lytic lesions from metastasis or plasmacytoma, or other bone-based cancers. Sometimes flexion/extension films are helpful, since MRIs are almost always static and supine (until dynamic MRIs obtain more widespre...
Do you find IgA isotypes of anti-beta2-glycoprotein antibodies and anticardiolipin antibodies to be clinically useful in the evaluation for APS?
There are conflicting views on this topic. A recent study of 1068 persons found that while IgA B2glycoprotein antibodies were associated with APS, isolated IgA antibodies did not portend thrombotic risk. Chayoua et al., PMID 32696448. They are not currently part of the criteria for APS. So my answer...
What bDMARD would you choose for a patient with RA with high infection risk and inadequate response to cDMARDs?
This is an important question and a prime example of the "art of rheumatology" where we must balance the risk and benefit of targeted therapies of treating active RA and adverse events such as serious infection. Ideally, we would have many head-to-head trials of every agent adequately powered to ans...
In your experience, is there an association between interstitial cystitis and systemic lupus erythematosus?
There are reports of interstitial cystitis associated with lupus. I have had two patients with that combination, one that is particularly severe. Lupus may or may not be active at the time. There are case reports in the literature of different treatments to try as the standard drugs may not be effec...