Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you ever combine voclosporin and belimumab in the treatment of lupus nephritis?
The combination of these two therapies has not yet been formally tested. Having said that, the combination has an appealing rationale. Immunologically, modulating T cells and B cells in LN seems likely to be efficacious. Beyond the immunology, there are other reasons that favor this combination. Voc...
Should all patients with suspected giant cell arteritis get a PET scan to look for large vessel disease?
PET-CT and PET-MRI can be very useful diagnostic modalities in GCA, but I do not recommend universal screening with PET scanning. The upcoming ACR/VF sponsored vasculitis guidelines will likely recommend obtaining non-invasive vascular imaging to evaluate for large vessel involvement, but the recom...
How do you weigh the risks and benefits of GLP-1 RAs in patients over age 65 specifically in regards to loss of muscle mass and osteoporosis?
This is indeed a crucial question: rapid weight loss is accompanied not only by a loss of adipose tissue but also by a loss of lean mass, including muscle and bone tissue. This must therefore be taken into account when making decisions, particularly in patients with osteoporosis, frailty, sarcopenic...
What lab monitoring and frequency do you recommend in an otherwise healthy young patient on biologics for psoriasis?
Yearly QuantGold testing in low risk patients has been shown to be unnecessary and actually carries a significantly higher risk of false positive than true positive. Unfortunately, many insurers still require yearly testing. I don't know of any data to support any other yearly lab testing for the dr...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
How do you make the decision to empirically treat for GCA when a patient is referred but cannot be immediately seen in clinic?
This is an important question because referrals for possible GCA are common scenarios when a rheumatologist may be asked to recommend a treatment before seeing the patient which are often challenging scenarior. The factors I typically rely on to rate the probability of GCA include: - Specific sympto...
Do you ever consider tapering off steroid-sparing agents in patients with stable non-IPF ILD?
In short, the answer is YES—I always look for ways to reduce immunosuppression exposure over time and use the lowest effective dose required to keep a patient’s inflammatory ILD in check. I often remind myself that when these patients present with a mixture of fibrotic changes (e.g., traction bronch...
How do you ensure that fibromyalgia is appropriately recognized in patients with Sjogrens?
I like Dr. Pisetsky et al's recent recommendation of naming this "nociplastic pain" rather than fibromyalgia. They were specifically talking about "lupus-associated nociplastic pain", but after reading their article, it should also apply to Sjogren's disease.I'd encourage everyone to read their very...
How do you counsel a patient with Sjogren's and extremely dry mouth who is losing their ability to taste food?
First, I assess if oral candidiasis is present; if so, treat. Consider if there are other cofactors that may be present, such as laryngopharyngeal reflux, B12, or Zn deficiency. If the taste buds are atrophic, you could try oral coconut oil or Vitamin E… but it’s tough. I consider, but it is hard to...
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...