Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How long do you continue immunosuppression in patients with Behcet's who have a history of mucocutaneous and ocular disease, but are now in remission?
There are insufficient data to answer this question comprehensively at this point. Some have studied anti-TNF withdrawal in Behçet’s uveitis, but the results do not yet allow conclusions that are firm enough to direct patient care, in my opinion. In every Behçet's disease (BD) patient, it is crucia...
How common are nasal telangiectasia in patients with systemic sclerosis?
Telangiectasias, particularly “matted’’ ones are often seen in patients with Systemic sclerosis (SSc), both limited and diffuse cutaneous. They can also be seen in patients with MCTD, UCTD with SSc features, Lupus or Dermatomyositis (often periungual). In SSc, they are most commonly on the face and ...
What is your approach to rheumatologic disease management during the current methotrexate shortage?
This is a great question for numerous answers across the MedNet community! For the “DMV” (DC, Maryland, and Virginia for those who are not familiar with the acronym) I can say this have been an intermittent problem but not a major disturbance in care. I have switched some people to “injectable” but ...
How would you approach choosing osteoporosis treatment in a patient with a T score -3.3 in lumbar spine and no prior fracture history who has squamous cell cancer and received radiation therapy?
This is an interesting question and a not unfamiliar clinical situation. I would like to know the age of the patient of course and her general medical health including renal function as that might influence the choice of drug to be recommended. The underlying premise here (I assume) is the option of...
Would you consider teriparatide in a postmenopausal woman with normal DEXA who had a traumatic humerus fracture three months prior with surgical intervention and plain Xrays showing only partial healing?
At NYU, we have a multi-disciplinary approach to fracture non-unions and have used teriparatide in that setting usually at the request of our fracture surgeons. Those patients are not truly comparable to the patient described in your question as the non-union patients' fractures occurred significant...
What is your workup for CSF studies when evaluating for possible CNS Lupus?
CSF studies for CNS lupus are most important in ruling out non-lupus CNS problems, e.g. infections and malignancy. So you want to target CSF studies toward the differential diagnosis of the presenting CNS phenotype. Typically these would include cell counts with diff, glucose, total protein, CSF IgG...
What is your preferred steroid sparing agent in the treatment of Sjögren associated LIP?
There is unfortunately very limited data comparing the efficacy of various steroid-sparing agents for the treatment of connective tissue disease-related ILD, and no large prospective studies have specifically addressed the ideal approach for patients with underlying Sjogrens. Mycophenolate and azath...
How would you approach the management of a patient with tophaceous gout who consistently has a serum uric acid under 5 on allopurinol but continues to experience gout flares?
I have a slightly different take on this question than Dr. @Dr. First Last. We don’t know from the question when allopurinol was started, what the current dose is or if the patient’s gout is tophaceous. Flares are commonly seen for several months after oral uric acid lowering therapy (ULT) is initia...
How would you approach a patient with elevated CPK in the 500-1000 range with no weakness on exam or myositis on MRI but with positive HMGCoA ab?
No treatment but follow closely for weakness and muscle enzyme further elevation. If CK starts to go up and doubles and triples, or weakness start, then start treatment as soon as possible.
Would a surgical decompression be indicated in a patient with amyloidosis and severe median neuropathy at the wrist?
Yes, of course, if the median neuropathy is symptomatic. I am not aware of any literature suggesting lower rates of success with carpal tunnel release surgery in patients with various amyloidosis subtypes compared to non-amyloid CTS.