Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to seronegative presumed pediatric autoimmune encephalitis?
My approach is to prove that the patient has that condition through objective testing (labs, imaging, tissue sampling) instead of having a "presumed" diagnosis as I do not treat patients based on presumptions...
Are there concerns with combining anti-IL5 biologics (mepolizumab or benralizumab) for severe asthma with other biologics for RA?
The question of combination biologic therapy is becoming increasingly important in our field. The main concern with combination biologic therapy is the risk of serious infections. This concern extends to IL-5 agents combined with biologics for RA. Unfortunately, there is a lack of data to guide our ...
What is your second line therapy for patients with EGPA with mainly pulmonary and sinonasal features who did not respond to mepolizumab 300 mg/month and still require high doses of steroid?
This is an important question. Benralizumab has recently been shown to have similar efficacy to mepolizumab with a suggestion of a greater number of patients being able to fully discontinue steroids when treated with benralizumab as compared to mepolizumab. On the basis of this study I would use ben...
Are there benefits to adding IL5/IL5 receptor blockade in patients with vasculitic manifestations of EGPA?
While IL-5/IL5 receptor blockade has been shown to be efficacious in treating "eosinophilic" manifestations of EGPA, including asthma and nasal polyps, there are real-world studies that demonstrate its effectiveness in what we consider "vasculitic" manifestations of the disease as well. I personally...
Are there any new treatments for erosive osteoarthritis of the hands?
Unfortunately, the short answer is “no.” Hand OA, in general, is one of the more refractory forms of OA, and erosive OA is even more so. A variety of theoretically useful approaches have been tried, based on our understanding of inflammatory arthritis in general. However, recent placebo-controlled t...
Given the risk of hypocalcemia in dialysis dependent patients treated with denosumab, what is the best method of treatment for osteoporosis for these patients, and should we be transitioning to a different agent?
Hypocalcemia can be prevented by providing adequate calcium, 1,200-1,500 mg in divided doses daily, and adequate calcitriol to absorb it. Good results also occur when the patient has tertiary hyperparathyroidism with hypercalcemia.
What is your preferred management approach for scleroderma renal crisis in a patient with a history of anaphylaxis to ACE inhibitors?
The important thing is to lower the BP regardless of the how. ACE I were the first medication to show survival benefit in patients with scleroderma renal crisis so they have become the treatment mainstay. Time is kidney so the best treatment is to lower the BP with whatever BP lowering medication yo...
Do you routinely pursue cardiac evaluation in children presenting with post-streptococcal reactive arthritis given the diagnostic overlap with acute rheumatic fever?
Yes.
Do you recommend medical therapy for extensive atraumatic osteonecrosis of the femoral head to mitigate pain or prevent femoral head collapse?
This is a good question. Extensive atraumatic ON of the femoral head will probably not respond to any medical therapy; eventually, the patient will need a replacement. However, ON that is from a systemic insult (drugs, alcohol) is often bilateral so if the other hip is less affected or not affected,...
Do you continue methotrexate while starting TNFi therapy in patients with refractory pulmonary sarcoidosis?
No clear data to do this in an EBM fashion in my opinion. I keep the baseline anti-inflammatory agents the same for the initial two doses of infliximab and once they are on regular dosing, I decrease the other agent/s. After steady-state, I would still keep a low dose of prednisone (2.5 or 5 mg dail...