Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you taper tocilizumab in a patient treated with the GIACTA 26 week steroid and tocilizumab protocol?
This is a very important question that should be high on the research agenda in GCA in the coming years. Several studies investigating the risk of relapse in GCA have yielded relapse rates ranging from the 30s-70s%. While these studies have significant limitations, it's reasonable to assume that the...
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
I am a radiation oncologist and palliative care physician.I teach: "the hand that writes the opioids, writes the laxatives - or else it does the disimpaction". Opioid induced constipation is very common, can cause physical and psychological discomfort, and have a major impact on quality of life. It ...
How do you approach immunosuppression in patients with rheumatoid arthritis and newly diagnosed bladder cancer who willl be starting intravesical BCG therapy?
I agree with Dr. Cappelli but there is an additional layer to the question. The concern is not just with efficacy of BCG treatment for bladder carcinoma when on these medications. There is the concern than anti-TNF therapy may increase the risk of dissemination of BCG, analogous to the experience wi...
Are there any concerns with live vaccine innoculation and patients who are on denosumab?
This is a complicated question because while denosumab is a biologic therapeutic that has immunomodulatory effects on innate and adaptive immunity its association with serious infections complications appears modest. An increased rate of background infections and some increase in serious infections ...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
How do you approach the work up for patients with fibromyalgia and hypermobility?
I agree the folks that are hypermobile are very challenging and it can be difficult to feel confident in hypermobile EDS diagnosis, particularly with sort of nebulous criteria. I have also found that medical genetics referrals where I practice have over a year-long waitlist, and as there is no genet...
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
In older male patients with a history of underlying autoimmune disease, what clinical manifestations would prompt you to evaluate for VEXAS Syndrome?
Hello!!!Skin lesions, elevated MCV, elevated inflammatory markers.
How would you counsel a patient with relapsing polychondritis who is considering a turbinectomy for nasal obstruction regarding potential risks and disease-related complications?
Thank you so much for thinking so carefully about this!!.<3 <3 When I talk with a patient who has relapsing polychondritis and is considering a turbinectomy for nasal obstruction, I try to acknowledge how difficult and frustrating these symptoms can be, while also making sure we keep their safety a...
What biologic or conventional/synthetic DMARD would you use as a steroid sparing agent in a patient with GCA and a history of diverticulitis?
This is an important question. Both IL-6 inhibitors and JAK inhibitors have a risk of bowel perforation which is increased in patients with a history of diverticulitis, therefore, these agents must be used with great caution in such patients and alternative therapies are often preferred.First, it's ...