Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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.
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 ...