Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach management of a patient presenting with clinical manifestations of systemic sclerosis (cutaneous involvement, Raynaud’s phenomenon, and pulmonary arterial hypertension) but negative serologies?
Systemic sclerosis is a clinical diagnosis, and there are patients who don't demonstrate antibodies on currently available clinical labs. In addition, there are patients with mild phenotypes who may also not meet the current classification criteria. I think if the clinical syndrome is consistent wit...
Do you continue PJP prophylaxis indefinitely in patients on rituximab maintenance therapy?
Risk for PJP infection is usually in the context of moderate-high dose corticosteroid therapy or low T cell counts.
How would you approach diagnosis of a patient with recurrent episodes of abdominal pain, severe myalgias, low grade fevers and urticaria?
Without the mEFV variant, from a rheumatologist viewpoint, the differential includes IBD, a periodic fever syndrome such as FMF or FCAS, and MCAS. Therefore, I would consider that workup with genetic testing (anyone can send!), fecal calprotectin, and MCAS eval with A/I. I don't think of urticarial ...
How would you counsel a woman with a strong family history of thrombosis about oral contraceptives?
This can be a complex question for which there are likely no specific data or guidelines upon which to base a recommendation. ASH has published guidelines on thrombophilia testing in VTE (Middeldorp et al., PMID 37195076). They specifically recommend against testing prior to COC prescription. The ra...
How do you approach the management of autonomic neuropathy in a patient with Sjogren's?
Early on in working with autoimmune patients, I had access to neurogastroenterology specialists and gained an appreciation for GI dysmotility disorders. In addition to Scleroderma, Sjogren's patients frequently had documented abnormalities on motility studies. Neuro and immune abnormalities can lead...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
Is there any role for prophylactic DMARD therapy to prevent immune-related adverse events (irAEs) in patients receiving immune checkpoint inhibitors?
Excellent and timely question!There are no good studies-- but I truly believe this is where we are heading for cellular therapies and IO. I am unsure if it will be DMARDs, as lung cancer patients get premetrexed with IO and still develop irAEs-- it will more likely be bDMARDs.The reason, I believe, ...
What is your approach to management of recurrent Kikuchi-Fujimoto Disease?
My experience with recurrent Kikuchi–Fujimoto disease (KFD) is limited, as I have not managed many recurrences; however, this is the general framework I use in practice. At the time of a recurrence, I first reassess the diagnosis and consider potential mimics—particularly infection, lymphoma, and ev...
In patients with relapsing polychondritis with suboptimal response to NSAIDs and prednisone, what are strategies you use for flare treatment?
It depends on multiple variables, including organ involvement, disease activity, and associated manifestations. I would be happy to discuss it further if you would like.
What minimum clinical features or risk factors drive you to obtain a baseline HRCT in a patient with RA or Sjogren's disease?
Overall, about 10% of RA patients will develop clinically significant ILD, as will 20% of those with SjD. Those are a significant number of people, and ILD should be on our radar as clinicians. Knowledge of risk factors for ILD can help us focus on people most likely to be affected. Several risk fac...