Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach management of active bilateral pan uveitis in patients who have a history of prior infectious uveitis?
The first step in the approach to such a patient is information gathering. What type of infection caused uveitis in the past? How and for how long was it treated? What was the ocular disease phenotype in the past, what is it now (exceeding the definition of "panuveitis"), and what evidence exists to...
Which biologics are you comfortable combining with vedolizumab for spondyloarthritis or psoriatic arthritis patients in the setting of well-controlled inflammatory bowel disease?
Historically, rheumatologists have been hesitant to combine biologics in our patients, based largely on trials from 20 years ago that found an increased risk of serious infections when combining a TNF inhibitors and an IL1 inhibitor, or abatacept and another biologic. With the availability of newer ...
What is the optimal timing for Zoster vaccine administration for a patient who recently recovered from herpes zoster infection and is now planning to start B-cell depletion therapy?
This is a complicated question that must balance two competing factors. First, in general, most experts counsel waiting, approximately one year after zoster before vaccination in attempt to take advantage of endogenously boosted immunity and a low rate of recurrence within 12 months. On the other ha...
How would you approach persistent episcleritis/uveitis due to PR3+ GPA, which needs low dose prednisone to control, despite induction with Rituximab?
In patients who have refractory inflammatory eye disease despite rituximab, I have worked with ophthalmology to determine whether baseline escalation in immunosuppressive medication is indicated or if targeted organ therapy is an option. In general, there is more urgency when there is chronic active...
What is your approach to evaluating a patient with known rheumatologic disease and elevated free kappa:lambda ratio, but no evidence of monoclonal immunoglobulins?
The information given is a bit sketchy. But assuming a bone marrow biopsy has been done and there is no evidence of malignancy, I would adopt a watch-and-wait approach. If no bone marrow has been done, I would keep an eye on the appropriate blood tests and in collaboration with a hematologist do a b...
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...