Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to treatment of severe intestinal vasculopathy in patients with myositis (such as NXP2)?
Avoid NSAIDs and agents that can cause gastritis or GI ulcers. IVIG is the best treatment for such patients.
Is there a preferred JAK inhibitor for the treatment of alopecia associated with childhood-onset systemic lupus erythematosus?
Unfortunately, this question likely comes down to FDA and insurance approval and not scientific evidence. Since only one JAKi is approved for alopecia right now and and 2 for poly JIA and none for SLE currently in any age, it will come down to which diagnosis you are going to use to get coverage.
Do you think the benefits of performing a repeat kidney biopsy to assess histologic evidence of disease activity or chronic damage outweigh the risks in a patient with recently treated lupus nephritis and improving creatinine levels?
In patients with lupus nephritis who have recently undergone treatment and are demonstrating improved creatinine levels, performing a repeat kidney biopsy is generally unnecessary. The risks associated with the procedure do not justify its benefits unless there is persistent or worsening proteinuria...
What were your top takeaways in Myositis from ACR Convergence 2025?
ACR Convergence had an outstanding selection of myositis offerings, and the number of people attending the sessions reflects the increasing recognition of these heterogeneous diseases, coupled with the frequency that non-myositis specialist clinicians will encounter these entities. The convention pr...
What specific criteria or patient conditions would make you hesitant to use fluoroquinolones early in the treatment course for managing MSSA joint infections with oral antibiotics?
For MSSA joint infections, I have moved away from using FQ to using high-dose cephalosporins as a step-down therapy, particularly cefadroxil 1 g twice daily, given less frequent dosing/increased adherence. Considering the risk-benefit analysis, I prefer using FQ as an oral option in polymicrobial an...
How would you approach managing a patient with well-controlled RA on abatacept who develops a solid malignancy?
Ok- good question:I would switch to an IL6inhibiton and let oncology do their thing.Make sure they are on Plaquenil too. :)Also, if the patient is going to get traditional chemo - watch and wait, likely the RA will be controlled with blanket immunosuppression of chemotherapy.Petit et al., PMID 39241...
What strategies have you found most effective in improving long-term medication adherence in patients with SLE?
The most important long-term drug to have good adherence to is hydroxychloroquine.Soon after I began measuring HCQ drug levels in all my patients who were not in remission back in 2016, I was shocked at how many were not taking it very well (lived up to the low adherence numbers quoted in the litera...
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
Would you have concerns using azathioprine in NXP-2 or TIF-1 gamma positive dermatomyositis patients due to higher risk of malignancy?
No studies have examined the effect of long-term azathioprine and the risk of malignancy in myositis. However, data from other autoimmune diseases (like lupus, myasthenia gravis, multiple sclerosis) have been negative in most cases (except perhaps for rheumatoid arthritis), and distinct from what is...
Would you have any concerns about starting an anti-TNF in RF and anti-CCP positive RA patients who also have high titer ANA?
No, I would not have any concerns. A patient with seropositive RA who demonstrates a positive ANA remains a patient with RA, not someone with an overlap connective tissue disease syndrome. Since a positive ANA can be seen in a sizable percentage of healthy people and among those treated with TNFi dr...