Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there any risk factors for IO induced rhabdomyolysis and how do you approach and manage it?
IO can affect the muscle in many ways. There is a myasthenia gravis and myositis overlap. I am not sure we know whether it is rhabdomyolysis versus a CK leak vs steroid myopathy vs muscle necrosis due to something else. Did the patient have EMG or muscle biopsy? There is a lot we do not understand a...
How do you approach methotrexate management in patients with rheumatoid arthritis and moderate NASH but no fibrosis per FibroSURE?
In this scenario of a patient with defined NASH by Fibrosure or alternative biomarker or predictive index of fibrosis, I would refer for baseline Fibroscan (transient elastography) to determine the degree of steatosis and presence/degree of fibrosis. NAFLD is common in our population with an estimat...
How would you approach an elderly patient with tibial plateau insufficiency fracture and normal DEXA?
Tibial plateau fractures are common among young individuals and often the result of trauma or injury. In the elderly, they can be related to injury but as well as poor bone strength and quality. In the aging population if DXA testing is normal and the fracture is not the result of major injury searc...
Is it safe to give radiation to a breast cancer patient with discoid lupus?
In published data with whole breast, it is well tolerated and we don’t consider this as a contraindication to BCT.
Can APLS cause a false positive HIT ELISA?
Yes, that has been reported: Pauzner et al., PMID 19291166.
Is there a role for low dose aspirin in a patient with AVN in four large joints who has underlying well-controlled SLE and positive APLs but no history of clots?
AVN in SLE patients is common, most often in the context of glucocorticoid use. Thus, in this case, there is no evidence that APLAs are the etiology. Moreover, to the best of my knowledge, there is no evidence that primary prevention with aspirin in the setting of APLAs is effective. So I would not ...
What is your approach to discussing risk of adverse cardiovascular events in patients with RA whom you are considering starting a JAK inhibitor?
I would refer to the recommendations in the January 28, 2022, position statement by the American College of Rheumatology. This statement emphasizes the importance of shared decision making between the rheumatologist and the patient. There are many options available to treat RA that do not have a sim...
What is your approach to tapering therapy in a patient with recurrent pericarditis now well-controlled on rilonacept?
Good question, since rilonacept was only approved 1.5 years ago, a lot of this is gleaned (i.e. expert opinion) from those that participated in the Rhapsody clinical trial.In terms of actual data, the long-term follow-up from Rhapsody was just presented at AHA.2022. Of those in the extension that de...
Are there any concerns utilizing apremilast for psoriatic arthritis in patients who are also taking roflumilast for COPD?
This is an interesting question which I don't have a good answer for. In my experience, I have not used the combination and upon my review of the literature, I did not find any reported use of the combination. Roflumilast is currently being studied in and shows efficacy in psoriasis both in topical ...
What are your top takeaways from ACR 2022?
Risk stratification for cardiovascular risk with JAKi (Ytterberg et al., PMID 35081280 and more specifically subgroup analysis by Charles-Schoeman et al., PMID 36137735): heightened risk in patients with history of atherosclerotic CV disease-ASCVD (defined as CAD, stroke, PAD)-NNH only 16 over 5 ye...