Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend vasodilators in patients with Raynaud's who have capillary drop out but are otherwise not bothered enough by their symptoms to want to pursue systemic treatment?
I typically do not unless they have had ischemic events in the past (like pitting or ulcers). Unfortunately, we do not have good longitudinal data to support the idea that prophylactically treating patients with vasodilators when they are otherwise minimally symptomatic will have a preventative role...
In a patient with strong serologic evidence of SLE presenting with isolated bilateral lower limb sensorimotor neuropathy, normal neuroimaging, and CSF, would you initiate cyclophosphamide with pulse-dose steroids upfront, or reserve escalation (e.g., plasma exchange or immunosuppressants) for cases refractory to steroids?
This has been a dilemma for me for over several decades.1. There is no good large data to guide us on this question. I do not think there is one correct answer.2. All sensorimotor neuropathies are not created equally. I assume all other causes of sensorimotor polyneuropathy have been ruled out. Howe...
How do you counsel patients about the potential malignancy risk associated with traditional DMARDs?
I discuss with them the slight increase of non-melanoma skin cancer in studies of methotrexate. Otherwise, there is not convincing data of associations between csDMARDs and cancer development.
Do you find 14.3.3 eta or vectra DA helpful in clinical practice?
These blood tests were developed to help diagnose and monitor rheumatoid arthritis.14-3-3 eta is an interesting protein that may have pro-inflammatory properties and could be helpful in diagnosing RA (Maksymowych et al., PMID 25128504), confirmed in a recent meta-analysis to have reasonable diagnost...
What serologic biomarkers do you send to assess for sarcoidosis at baseline and/or during flares, in patients where it may correlate with disease activity?
Elevated ACE, dihydroxy vitamin D, and soluble IL2r levels have been shown to correlate with disease activity, but it is important to keep in mind that the sensitivity and specificity are variable and they should never be used in isolation to diagnosis or assess disease activity in sarcoidosis. The ...
How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?
As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD...
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
I think it would be important to know the doses of the medications 'failed'. Similarly to allopurinol dosing and gout prophylaxis 'failures', I find most patients I see for consultation with this story are not on high enough doses, need combo therapy, or are not on the medication long enough. Meth...
When transitioning from romosozumab to alendronate or teriparatide to alendronate, is there a minimum amount of time that alendronate needs to be continued to prevent loss of BMD gains?
My personal approach is that the transition to an anti-remodeling drug like alendronate should be done ASAP to reduce the risk of losing new bone that was made with the anabolic drug. The length of use of alendronate should be consistent with our typical use of oral alendronate. Generally, no more t...
How do you manage a patient with SLE with acute bilateral sensorineural hearing loss refractory to high dose systemic and intratympanic steroids, normal MRI brain and APL labs?
Interesting, as I just saw a case almost exactly like this one (except my patient was unilateral)! I question whether systemic lupus erythematosus is truly the cause of the hearing loss. If immunologically induced (ie, autoimmune hearing loss), I'd expect to see at least some objective improvement o...
How do you approach screening for occult cardiac or tracheal involvement in a patient with relapsing polychondritis?
Hello! Dynamic CT and echo, if you have suspicion of vasculitis (physical exam, sx), a CTA can help. Happy to discuss your case.