Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
Assuming lab accuracy, what are some of the hallmarks and symptoms that would lead to a diagnosis of ANA-negative lupus as opposed to any other autoimmune condition?
I would not make an initial diagnosis of ANA-negative systemic lupus erythematosus (SLE) lightly, especially since there are so many mimics of SLE. However, it does occur, even in early, untreated patients. Even some of the best lupus centers in the world (SLICC) have a 6% prevalence of ANA-negative...
When do you recommend initiation of targeted therapies in active RA with history of malignancy?
In patient with RA and a history of malignancy, I generally recommend the same therapy that I would recommend in the absence of a malignancy history. This is consistent with the most recent ACR guidelines for the management of RA (Fraenkel et al., PMID 34101387). Consistent with FDA labeling, I'd ge...
How would you approach the treatment of erosive inflammatory arthritis (RA or SpA) in a patient with multiple sclerosis on ocrelizumab who has failed csDMARD therapy?
This is a challenging situation to confront, however, as more non- rheumatological illnesses are being managed with biologics, we will be facing this issue with greater frequency. Regarding multiple sclerosis (MS), one should be aware that the major metabolite of leflunomide, teriflunomide, is a bra...
Do you always perform salivary gland biopsy to confirm the diagnosis In patients with suspected seronegative Sjogren's syndrome?
I often struggle with the decision of obtaining a biopsy in suspected Sjogren's in a person who is seronegative, when the main issue is dryness, and the main reason is that I wonder if it will make a difference in management. When I was a Rheumatology fellow, I was taught to give Hydroxychloroquine ...
What is your approach to refractory oral ulcers in SLE?
Would not consider only trying HCQ as being refractory. Many more lupus medications to be tried! Azathioprine, MMF, Methotrexate, and Benlysta would all be under consideration. I presume their labs show some aspect of active SLE.
What is the next best osteoporosis treatment option for patients who completed 2 years of teriparatide, but has contraindication to bisphosphosnate therapy (e.g. history of atypical femur fracture)?
I have successfully treated several patients with bisphosphonate-induced subtrochanteric femoral fractures with Forteo. However, before initiating another antiresorptive therapy, I first want to be sure that the Forteo at the desired effect on bone remodeling by increasing both bone formation and bo...
Would you choose bimekizumab over other IL-17 inhibitors in patients with increased levels of disease related pain and poor functional status?
In the absence of head-to-head trials, I hesitate to make a recommendation regarding which IL 17 inhibitor is better in this situation. It is also very unlikely that the makers of the three IL 17 inhibitors would conduct such trials. Network meta analysis and matching-adjusted indirect comparison ar...
What factors drive you to prioritize treatments that inhibit T cells vs B cell depletion when choosing therapies for patients with refractory SLE?
Other than for immune cytopenias that are likely primarily autoAb mediated it is difficult to know the relative extent to which T cell vs humoral immunity effects lupus disease activity. As such, the main driver for me to target T-cell activation currently would be organ complications not known to b...
How do you approach the initial treatment for a patient presenting with MAS/HLH as the initial manifestation of SLE?
For rare manifestions of systemic lupus erythematosus (SLE) such as macrophage activation syndrome/hemophagocytic lymphohistiocytosis (MAS/HLH), I like to refer to the recent paper by the Members of the European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, th...