Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you work with patients to establish reasonable treatment goals for the management of fibromyalgia-related pain?
Great question. I explicitly tell my patients that I have no magic-bullet– no penicillin or prednisone-adjacent pill – that will swiftly and reliably alleviate their pain. This expectation, that a pill will eradicate disease, makes sense in the wake of the infectious disease revolution, where target...
How soon after starting treatment for Takayasu arteritis do you decide on the need for any vascular interventions to manage chronic damage?
To answer this question, several elements need to be considered. As a rule of thumb, in TAK and large vessel vasculitis in general, it is recommended to perform vascular surgery at the time of disease remission to prevent complications during the surgical procedure and in the immediate postoperative...
For which SLE manifestations or disease activity markers do you generally recommend escalation to a biologic in a patient who does not have apparent renal involvement?
For renal lupus, mycophenolate is no longer sufficient as induction therapy: either belimumab or calcineurin inhibitors should be added. For non-renal lupus, EULAR 2023 guidelines (Fanouriakis et al., PMID 37827694) state that immunosuppressives and/or biologics can be added. Gatto et al have shown ...
What is your approach towards continuing cancer screening in a young adult with Tif-1+ dermatomyositis, and negative initial CT chest/abd/pelvis?
Young TIF-1 is likely behave as juvenile DM with TIF-1, where the risk of cancer is much lower. I have many young TIF-1 that never developed cancer. I still think that careful ongoing monitoring is needed for 3 years from diagnosis. For cancer risk assessment and management, use the International gu...
Do you use bone turnover markers to assess medical adherence in patients treated for osteoporosis?
I find the bone remodeling markers very helpful. First and foremost, I want to be sure that if I am going to put a patient on an antiresorptive medication that the patient has evidence for high bone turnover over i.e., increased osteoclastic activity. If the bone remodeling markers for both bone for...
How do you approach patients with fibromyalgia who are reluctant to consider a psychiatric component to their illness but present with clear mood or anxiety symptoms?
Since patients with fibromyalgia (FM) are often stigmatized and worried that clinicians think “it is all in my head,” it is important to discuss FM treatment and mental health referral from a biopsychosocial perspective. This might include introducing concepts such as the pain/depression dyad, centr...
What laboratory studies do you routinely order when evaluating a patient with interface dermatitis on biopsy?
Rule out lupus.
What do you recommend to patients when they are having an acute flare of fibromyalgia symptoms?
Great, this is a really important area and unmet need in the field of fibromyalgia management. Unlike other nociplastic disease states (e.g., migraine), there are no rigorously studied abortive therapies to rapidly treat a flare of centralized pain. Indeed, all the therapies we use for FM are intend...
What is your approach to treatment of severe intestinal vasculopathy in patients with myositis (such as NXP2)?
Avoid NSAIDs and agents that can cause gastritis or GI ulcers. IVIG is the best treatment for such patients.
Is there a preferred JAK inhibitor for the treatment of alopecia associated with childhood-onset systemic lupus erythematosus?
Unfortunately, this question likely comes down to FDA and insurance approval and not scientific evidence. Since only one JAKi is approved for alopecia right now and and 2 for poly JIA and none for SLE currently in any age, it will come down to which diagnosis you are going to use to get coverage.