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