Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Have you used JAK inhibitors with TNF blockade at the same time?
Generally, no. For three reasons: I find the addition of a JAK inhibitor to a TNF inhibitor to be too immunosuppressive with a high risk of infection and/or malignancy. If I am choosing a JAK inhibitor, it would serve to "replace" the TNF inhibitor usually, so I don't see a strong indication to sta...
How would you manage axial spondyloarthritis in a patient who was doing well on TNF inhibitor therapy then developed a new solid organ malignancy while on treatment?
The story here is an important one. I was able to discuss this with @Dr. First Last, who supplied important insights. Most of the good (and bad) data supporting what to do when your patient had a prior malignancy in remission or who develops one on treatment comes from experience with treating rheum...
When screening for malignancy, do you order CT with contrast (or) both with and without contrast?
I think the best way to think about this is to assess what each scan shows. A CT with oral and IV contrast is very good for assessing details between soft tissues and blood vessels. A CT without contrast is better for assessing for renal stones and for fractures, especially small insufficiency fract...
Should special precautions be taken patients with Ehlers-Danlos syndrome receiving radiation therapy?
Not all EDS is the same. Most commonly, an EDS patient these days is a clinically diagnosed patient with hypermobile joints, possibly stretchy skin, and possibly chronic pain syndrome. That is a very different picture from vascular EDS with a COL3A1 mutation, which is rare and would have the extreme...
How do you approach management of a patient with multiple lung nodules and low titer +CCP but no active joint symptoms suggestive of RA?
In the absence of other clinical symptomatology, I would favor close observation and follow-up in this case as there is no established diagnosis and repeat CT, PFT’s in 3 to 6 months. Details of initial evaluation should include PET-CT to exclude malignancy but also to investigate other organ system...
How would you manage a patient with discordant TBS adjusted T-score and traditional T-score?
The ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis) and IOF (International Osteoporosis Foundation) recommend the use of TBS-adjusted T-scores to help guide osteoporosis treatment decisions. However, this recommendation is based on a single research study and therefore may...
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
What circumstances would drive you to consider using an oral IL-23 inhibitor over parenteral options for the management of psoriasis and/or psoriatic arthritis?
Psoriatic arthritis is a heterogeneous disease and the choice of therapy is driven by many factors.The most important factors in the decision tree are whether the patient has 1) axial disease and/or 2) severe psoriasis.Additional Considerations include: prior therapies, extramusculoskeletal manifest...
Would you consider utilizing transdermal estrogen for HRT to treat severe hot flashes in a patient with SLE and a history of thrombosis x2 and positive lupus anticoagulant, but negative aCL/B2GP1 abs?
Given the prothrombotic effects of estrogen, they are generally avoided in patients with prior thrombosis and hypercoagulable states. Therefore, in a patient with SLE, secondary anti-phospholipid syndrome, as a single positive aPL with a positive lupus anticoagulant, and prior thrombotic event, the ...
Are you comfortable using belimumab in patients with a history of significant depression?
YES! (look at the numbers below)... edited as I accidentally initially said no. There was numerically increased suicidality and depression in the phase 3 clinical trials of IV belimumab (BLISS-52 and BLISS-76). Unfortunately, there were two completed suicides. Two things occurred due to this: Subseq...