Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In a patient who completed 5 years of oral bisphosphonate and has a T score persistently in osteoporotic range, what factors help you decide whether it is appropriate to start a drug holiday vs. switch to an alternative agent?
This is an interesting question concerning a common clinical issue. Unfortunately, I am unaware of any data (evidence-based medicine) that is helpful in answering the question. My response is thus only anecdotal. There is some good data that patients with an inadequate bone density response to three...
What is the role of kyphoplasty or vertebroplasty in patients with osteoporotic spinal fractures?
Vertebroplasty and kyphoplasty can be grouped together as vertebral augmentation. They have a single indication: To reduce pain arising from a documented vertebral fracture. Kyphoplasty has an inflatable balloon and in theory, can improve vertebral height prior to introduction of the cement. I am no...
How long do you expect gastrointestinal side effects of leflunomide to persist after stopping treatment?
Leflunomide (LEF) has a long half-lasting of about 15 days. So, when dealing with advise events such as gastrointestinal toxicity, these may persist up to several weeks following discontinuation of the drug. Simply discontinuing LEF will prove to be effective in the majority of patients with adverse...
In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?
I agree with Dr. @Dr. First Last. I have had patients with APS and recurrent thromboembolic events although not necessarily strokes to whom I have added aspirin and HCQ to the treatment regimen. I did this because she continued to have recurrent events. However, there is at least one article that ne...
How long would you consider the use of low-dose aspirin in a patient with SLE and high risk aPL profile (without a clinical event)?
I recommend low-dose aspirin (ASA) plus hydroxychloroquine (HCQ) to ALL my systemic lupus (SLE) patients unless they have risk factors for bleeding.I do this based upon the 2017 Italian study by Fasano et al. I explain to my patients that there are uncertainties to this recommendation and that furth...
In a patient identified as having APLS because of recurrent pregnancy loss without history of thrombosis, but now has a new DVT/PE during pregnancy despite use of enoxaparin—for how long would you recommend anticoagulation?
First, as far as I know, enoxaparin has not been proven to prevent pregnancy loss in obstetric APS. Second, we know that enoxaparin has not been shown to be as effective as heparin in preventing thrombotic events in APS. Third, the patient is pregnant, a thrombophilic state, separate from APS. All t...
How would you escalate therapy beyond MMF in a patient with rapidly progressive SSc-ILD?
These are very challenging patients. They are often young African American, males with a positive Scl 70 who may have a significant restrictive disease at the time of diagnosis. MMF seems to be the best approach but when there is the progression I do strongly consider adding nintedanib, and definite...
When do you consider referral to hand surgery for management of joint deformity in RA?
This is individualized to the patient's needs. If a patient is uncomfortable due to pain, quality of life or lack of function due to the deformity, I would arrange a consultation with a hand surgeon. Some patients do get distressed by the cosmetic appearance of the deformities and this is an indicat...
How do you monitor a patient with scleroderma during pregnancy?
One of the most important aspects of monitoring scleroderma patients in pregnancy is the preconception visit to review the stage of the disease including getting cardiopulmonary studies before pregnancy and reviewing medications and adjusting any immunosuppressive medications. Although prospective s...
Are there known biomarkers predictive of IRAEs?
While there are no FDA-approved biomarkers predictive of iAEs, there is a growing body of preclinic and retrospective research trying to address this important question. Eosinophilia may be a potentially useful biomarker and this is supported by several retrospective studies 1,2. It is intriguing th...