Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How does an incidental finding of low bone density on imaging done for another reason inform your screening approach for osteoporosis?
In patients with CKD, I would also look for changes on the plan radiographs of secondary hyperparathyroidism. For example, erosion of the distal tufts of the phalanges on hand films, erosion of the clavicle, and arterial calcification. If these findings are present, then it signifies hyperparathyroi...
How do you decide between initiating systemic immunotherapy versus local treatment for uveitis with associated HLA-B27 and spondyloarthropathy?
I find that most, but not all, HLA-B27 iritis can be controlled with topical therapies. To do so requires eliminating other causes of inflammation. Many patients have GI inflammation due to gluten and dairy, despite not having classic celiac disease or lactose intolerance. Reducing their intake, mod...
How do you incorporate hyperbaric oxygen therapy into the care of patients with wounds related to ischemic ulcerations?
Hyperbaric oxygen therapy (HBOT) is intended to improve local tissue hypoxia in non-healing ulcers. Evidence for its use remains limited, primarily consisting of case reports and small case series. Most documented cases involve lower-extremity ulcers, often related to macrovascular disease. For digi...
How often do you perform nailfold capillaroscopy in your clinical practice in patients with CTD?
In an ideal world, I would perform nailfold cap on all patients (to gain prognostic information on the extent of disease progression), but this is not feasible, and nailfold cap is not always necessary from a diagnostic perspective if the diagnosis is already clear. It is most useful when the diagno...
How do you approach the diagnostic evaluation of osteoporosis in CKD when renal dysfunction limits use of certain tests or biomarkers?
DEXA is still appropriate, and if anything, would underestimate the actual bone loss. For serum biomarkers, only TRAP5B, bone-specific Alkaline phosphatase (BSAP), and PINP are not altered with renal impairment (i.e., not partially cleared by the kidneys, leading to circulating fragments that render...
What is the maximum dose (mg/kg) you will push an IV TNFi to for a patient with Takayasu arteritis who is adherent and does not have evidence of anti-drug antibodies before switching to an alternate class of therapy?
For uveitis, I have used infliximab at 20 mg/kg/dose every 2 weeks to save vision.
How do you manage hypercalcemia in an osteoporosis patient on a PTH analogue?
Teriparatide should not be prescribed to patients with pre-existing hypercalcemia or underlying hypercalcemic disorders such as primary hyperparathyroidism, as it may exacerbate hypercalcemia.[1][2][3] The Endocrine Society recommends that serum calcium be assessed prior to use and that teriparatide...
Are there instances in which you would combine belimumab and rituximab for management of difficult to control SLE?
While I have not employed this combination in my own practice, I am aware of the proposed rationale that using belimumab and rituximab together could promote more sustained B-cell depression. This approach was tested in the BEAT-LUPUS trial, results published in Lancet Rheumatology in 2022. In this ...
How would you manage a patient with strongly suspected Lyme arthritis and negative bacterial synovial fluid cultures who was started on empiric antibiotics against typical bacterial pathogens arthritis before arthrocentesis and collection of cultures?
In a patient with a high clinical suspicion for Lyme arthritis who has negative synovial fluid bacterial cultures after receiving empiric antibiotics for presumed septic arthritis, management should be guided by clinical probability rather than the culture results. Antibiotics given before arthrocen...
Is Evenity appropriate for a patient with severe osteoporosis (T-score -3.1) unresponsive to bisphosphonates and persistent primary hyperparathyroidism despite two surgeries?
Before, I would institute therapy, I would like to know what the situation is with the primary hyperparathyroidism. Is this primary or FHH? Although a 24-hour urine calcium creatinine ratio is no longer helpful, I find that the serum phosphate and 1,25-dihydroxyvitamin D, along with 25-hydroxyvitami...