Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider adding dupilumab to adalimumab (or other monoclonal antibodies) in a patient who has RA and refractory atopic dermatitis and already is on MTX 25 mg weekly?
No. Unless the problem has been chronic since childhood, I would first run through the diagnostic checklist for adult-onset generalized dermatitis to be sure this is not a mimic of AD. If no other diagnosis is established after a thorough investigation, I would stop adalimumab and change to upadacit...
Is there any value in nonspecific inflammation seen on a salivary gland biopsy for making a clinical diagnosis of Sjogren’s disease in a seronegative patient with sicca symptoms (ie. chronic sialoadenitis with focus score 0)?
Unfortunately, nonspecific inflammation is unhelpful. In patients classified as having Sjogren's, the minor salivary gland biopsy will have a focus score of 0 in about 20% (Sharma et al., PMID 31092717). So you cannot rule out Sjogren's with a negative/non-specific biopsy. To meet the 2016 ACR/EULAR...
When in the treatment of OA do you think it is optimal to offer LDRT?
Evidence reality check: Two well-conducted sham-controlled RCTs (hand and knee OA) were negative for clinically meaningful benefit at their primary endpoints. (Minten et al., PMID 30231990, Mahler et al., PMID 30366945). ArthroRad (multicenter randomized, single-blinded) compared standard-dose vs ve...
What is the next best osteoporosis treatment option for patients who completed 2 years of teriparatide, but has contraindication to bisphosphosnate therapy (e.g. history of atypical femur fracture)?
I have successfully treated several patients with bisphosphonate-induced subtrochanteric femoral fractures with Forteo. However, before initiating another antiresorptive therapy, I first want to be sure that the Forteo at the desired effect on bone remodeling by increasing both bone formation and bo...
In which patients with CHE will you prioritize early use of delgocitinib?
I can't think of any that I'd prioritize specifically compared to other patients. Trial of high-potency topical steroids, then Anzupgo next visit if not doing great. Other key point is to stop the steroid when you start the Anzupgo - topical steroids have a very strong negative impact on barrier fun...
What monitoring would you pursue in a female patient with repeatedly very high titer centromere antibodies but no clinical symptoms of systemic sclerosis or other connective tissue disease?
For an asymptomatic patient with very high–titer anticentromere antibodies (ACA), monitoring should focus on early detection of systemic sclerosis (SSc) and related organ involvement, as higher ACA levels are associated with increased risk of progression. Risk stratification is informed by the devel...
In the treatment of osteoarthritis with low-dose radiation therapy is there data to support the claim that LDRT does not limit or preclude later orthopedic surgery?
At LDRT doses, the biological effects are anti-inflammatory and immunomodulatory rather than cytotoxic or fibrogenic, and there is no evidence of vascular injury, impaired cellular proliferation, or tissue destruction. Animal models and cellular studies provide robust evidence that LDRT at OA releva...
What maintenance regimen do you use for a patient with lupus cerebritis?
I prefer a mycophenolate analogue (MPA, usually mycophenolate mofetil, MMF, but prefer mycophenolic acid if on a PPI, which causes reduced MMF bioavailability, or if MMF intolerant) over azathioprine (AZA) for maintenance.Reasoning is that MPAs have shown better efficacy in improving outcomes and pr...
What factors drive you to prioritize treatments that inhibit T cells vs B cell depletion when choosing therapies for patients with refractory SLE?
Other than for immune cytopenias that are likely primarily autoAb mediated it is difficult to know the relative extent to which T cell vs humoral immunity effects lupus disease activity. As such, the main driver for me to target T-cell activation currently would be organ complications not known to b...
Do elevated neutrophils in the bronchoalveolar lavage of patients with sarcoidosis have any prognostic value?
Neutrophils in the alveolar space are uncommon in healthy non-smoking individuals, accounting for around 1% of cells in bronchoalveolar lavage (BAL). Macrophages compose 80–90% of the cells policing the alveolar surface, with the remaining cells being lymphocytes, rare eosinophils, and basophils. A ...