Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach treatment of PMR in a patient who has had avascular necrosis of the hip after starting steroids?
In this clinical scenario, I strongly advise avoidance of steroids. The data looks promising for using anti-IL-6 therapy in PMR. I don’t think it should be considered first-line therapy for our patients yet but should be reserved for those who have major contraindications or issues regarding the use...
How would you manage warfarin in a patient with APLS and alcoholic cirrhosis?
This is an interesting and challenging question that would require a case-by-case review by a team of rheumatologists, hematologists, and hepatologists, as well as an in-depth discussion of the potential risks and benefits with the patient. This reference, O'Leary et al., PMID 30986390, provides a g...
For a patient with osteopenia or osteoporosis, how long can intravenous zoledronic acid be maintained if there are not adverse events?
I generally prescribe Zoledronate annually for three years for patients with osteoporosis who are at increased fracture risk. I will occasionally add an additional treatment 18-24 months after the third infusion if there has been a positive response to the original treatment regimen and I feel that ...
Do you use MTX along with Rituximab in patients with early NSIP on HRCT in patient with active RA and polymyositis (PL7+)?
The reluctance of using methotrexate in ILD is mainly due to the risk of pneumonitis. So, I would use MTX in a patient with ILD if their pulmonary reserve is adequate to withstand a case of pneumonitis, which is a rare event. Otherwise, I would azathioprine or tacrolimus in combination with rituxima...
Is polymyalgia rheumatica associated with increased toxicity for lung SBRT?
No data here that I can speak to. Lung involvement is exceedingly rare in PMR and generally, I wouldn’t consider this a disease associated with increased risk of inflammatory response within the lung parenchyma. There are some reports of associated GCA, BOOP, and other interstitial lung findings in ...
In a patient with history of scleroderma renal crisis resulting in ESRD, would you recommend using steroids for when needed?
The frequency and timing of recurrent Scleroderma Renal Crisis are largely unknown. Majority of the reports available are from patients with ESRD that underwent renal transplant with recurrence in allograft - overall this is rare, with most occurring between 3 months to 2 years post-transplant, but ...
How would you treat a patient with necrotizing myopathy with positive anti-HMHCoR Ab unresponsive to standard therapies?
There are several questions raised by this scenario. I have personally never seen a patient with true HMGCR-antibody + necrotizing autoimmune myopathy fail a combination of 3 immunotherapies (high dose prednisone, IVIG, and either Rituximab or oral immunosuppression like Cellcept/azathioprine, etc),...
How would you approach a woman with APLA but no thrombosis/APLS, a history of ITP without bleeding who is now pregnant?
As a rheumatologist, I would want to make sure this patient does not have SLE. If no suspicion for SLE (and no previous obstetric complications), I would mostly likely monitor closely during pregnancy without any additional interventions.
Would you consider a biologic or JAK inhibitor to manage active PsA in a patient on chronic antibiotic therapy if they had previously failed all conventional DMARDs (including apremilast)?
IL-23i such as guselkumab have not really shown a significantly higher incidence of infections or malignancies, so I would favor these over other biologics. Ustekinumab (IL-12,23i) also showed lower rates of infection compared with other biologics. However, something to consider is whether they have...
How would you approach a patient with GCA who develops necrotizing fasciitis and then flares because they are off of tocilizumab?
While recurrent necrotizing fasciitis is exceedingly rare, patients with necrotizing fasciitis may be at higher risk for other infections. Therefore, a careful risk/benefit analysis is warranted in such a case, similar to other cases of serious infections in patients on immunosuppression. The specif...