Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you utilize ethyl chloride spray prior to steroid injections?
Ethel is not fully efficient. A spray may be inhaled and not good for the lungs long term.
What is your approach to using NIH activity and chronicity indices from renal biopsy in tailoring immunosuppression to a patient with new lupus nephritis?
I find the NIH activity and chronicity extremely valuable in LN management. If a patient has a high AI, I’m much more likely to be aggressive with corticosteroids to help stop the inflammation in its tracks. I will, of course, use a concomitant immunosuppressive/immunomodulatory agent as well (we no...
Do you continue to routinely screen for renal involvement in a patient with established Sjogren's syndrome who otherwise has only sicca symptoms?
In an article published in Rheumatology and Therapy in December 2021 titled Renal Disease in Primary Sjogren's syndrome. The authors encouraged yearly screening for renal disease as it can occur at any time during the disease course.
How do you manage calcium and vitamin D replacement in scleroderma and myositis patients with dysphagia and malabsorption?
Dietary calcium is a good choice. I recommended that my patients with dysphasia caused by scleroderma drink 2-3 glasses of skim milk daily. 8 ounces contain 300 mg of calcium which is highly bioavailable. It also provides a good source of whey protein that contains all the essential amino acids. Ano...
What additional immunomodulation would you consider in a patient with severe NXP-2+ JDM who has already received cyclophosphamide and rituximab but has persistent gastrointestinal vasculopathy?
I'd try a JAKi.
Is history of radiation therapy for uterine cancer an absolute contraindication to parathyroid hormone/parathyroid hormone related protein analogues such as teriparatide and abaloparatide in a patient with severe osteoporosis with multiple spine fractures?
I agree with Dr. @Dr. First Last. The initial studies in young rats given high doses of PTH compounds for most of their lifespan (I think until either 24 or 36 months of age) resulted in a higher-than-expected number of incident osteosarcomas. However, the black box warning about skeletal radiation ...
Would you consider antiphospholipid syndrome to be a contraindication for checkpoint inhibitor immunotherapy?
Checkpoint inhibitor therapy is usually an important treatment for patients with advanced malignancy, and has greatly improved the prognosis of otherwise untreatable cancers, so I would not automatically proscribe these drugs because of a history of APS. I would ensure patients with APS are on full ...
What treatment options do you recommend to patients with microstomia secondary to scleroderma?
Perioral and masseter botox 8U upper lip and 4U lower lip. 16U per masseter.
Do you offer anticoagulation to patients with prior antiphospholipid antibodies detected in pregnancy without a history of pregnancy loss or thrombosis?
I do not know what the risk of pregnancy loss is in a woman without a prior history of VTE or pregnancy loss. I am sure the risk is affected by whether the woman has an underlying rheumatological disease (SLE) and whether she has single positive vs. triple positive LAC. I recommend a baby aspirin on...
Do you recommend continuous antibiotic prophylaxis for patients on complement inhibitors such as eculizumab?
This is an extremely important and timely question. There simply isn’t enough data or firm guidelines on this leading to different practices. The reality is that there have been a number of meningococcal breakthrough infections in those vaccinated against meningococcal disease. Complement therapies ...