Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What Barrett's Esophagus screening protocol do you follow for patients with scleroderma given the increased risk of reflux and esophageal stasis?
This is an excellent question and is probably also relevant to mixed connective tissue disorder (MCTD) and overlap syndromes. My answer is a poor one - to my knowledge, we just do not have the data to guide us. I would certainly be more vigilant, but do not have a set protocol other than that for BE...
What is your approach to patients with SLE who develop a rash after hydroxychloroquine initiation?
First, I diagnose the type of rash. If it is a severe cutaneous reaction, e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis (SJS/TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), or if it is a more persistent type of reaction like a lichenoid reaction, I stop hydroxychlor...
How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?
Chronic urticaria (6 weeks or longer) is often a self-limited disorder seemingly idiopathic in etiology. There are certain autoimmune disease more prevalent in patients with chronic urticaria including systemic lupus erythematosus, Sjogren's syndrome, autoimmune thyroid disease, celiac sprue, and rh...
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
How do you approach inflammatory arthralgias without synovitis in a patient with psoriasis?
When a patient with psoriasis presents with inflammatory arthralgias, the approach should be centered on a prompt evaluation to differentiate psoriatic arthritis (PsA) from other causes of joint pain or non-inflammatory arthralgias. Clinical history and physical exam are the key. A good clinical his...
Are there patients with SLE associated inflammatory arthritis in whom you recommend TNF inhibitors as a treatment option?
In patients who have inflammatory arthritis due to SLE and other causes have been excluded, such as infection, gout, and CPPD, I avoid TNFi therapy due to the concern of flaring lupus disease activity. Alternatively, I tend to add therapy for which there is evidence-based data to support their use, ...
How would you approach the upfront management of a patient with acute unilateral vision loss with strong clinical risk factors for both cardioembolic stroke and GCA if an expedited MRI is not possible due to the presence of an AICD?
I'm definitely not an expert in this topic, but you have many clinical tools to increase/decrease your clinical suspicion for GCA vs. cardioembolic stroke. Some things I would ask: Is this patient currently in Afib? What's their CHADSVASC? Are they anticoagulated? Can we get a TTE to check for vege...
How would you manage a patient with arthritis mutilans who has failed TNFi, IL-17i, and JAKi and now on bimekizumab and with worsening joint disease?
Difficult case of destructive joint disease without a lot of options. If this is truly an "active" disease, and not just pain from prior joint destruction, the addition of cs-DMARDs to current therapy or adding 2 targeted therapies could be tried. TYK-2 (deucravacitinib) could be an option, but may ...
When do you prefer bariatric surgery such as sleeve gastrectomy or gastric bypass over an initial trial of a GLP-1 receptor agonist in patients with severe obesity and painful knee or hip osteoarthritis?
I believe that this type of decision should be made by obesity specialists and not by rheumatologists. However, we can anticipate that the patient's choice is paramount: some prefer radical options such as surgery, while others cannot bear to hear about it. The decision should only be made through d...