Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When would you consider discontinuing immunosuppressive treatment in a quiescent uveitis patient without systemic manifestations of inflammation?
I typically monitor patients on immunosuppressive therapy for at least 2 years before considering stopping or weaning off such therapy. There could be exceptions to this, including patients who insist on being taken off their meds (side effects, trying to conceive, etc.), in which case I can try aft...
How can we approach tapering or discontinuing biologic DMARDs in patient in their 80s with well controlled rheumatoid arthritis?
Not a simple answer, unfortunately, as we know Rheumatoid arthritis (RA) is a chronic disease and thus requires long-term treatment!If, however, the patient's preference is to taper or discontinue a biologic DMARD, per ACR RA treatment guidelines, it can be considered after the patient has been in r...
When discontinuing Denosumab after more than 2-3 years of therapy, when do you recommend giving the first dose of zoledronic acid?
My practice has been that after 2-3 years of denosumab, I wait 6 months and then start zoledronic acid.
How do you think about using Ropeginterferon Alfa 2B for polycythemia vera in patients with active autoimmune disease?
Great question. In general, I avoid interferons in patients who have an autoimmune disease. In the PROUD-PV/CONTI-PV study, a medical history of autoimmune disease was an exclusion criterion. There have been reported cases of interferon-induced autoimmune disease, most commonly autoimmune thyroiditi...
Do you have to extend treatment for acute Lyme disease if a patient is on high dose steroids for another indication?
I am unaware of any evidence to support longer-term therapy in such a setting. I am quite sure no such study has ever been done. Standard therapy for early Lyme disease is 10 days of appropriate antibiotics. Extending to 20 days would likely do no harm to the patient, but may not be necessary, and t...
What is the role of skin biopsy for evaluating small fiber neuropathy in patients with rheumatic disease who have treatment recalcitrant pain?
I have a shared decision-making discussion with the patient, especially alluding to the fact that the result would not change my therapy (i.e., use neuropathic analgesics for treatment) for small fiber neuropathy (SFN). Where I find it especially useful is in a patient with systemic lupus (SLE) or S...
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
When evaluating a patient with IgG4-related disease, are there particular exposures or risk factors you routinely ask about during the history to help identify potential contributors?
While there are no well-established environmental or occupational risk factors but taking a thoughtful exposure history can provide valuable information about the phenotype of the disease and help exclude mimics. I routinely ask about the history of allergic or atopic conditions such as asthma, alle...
When is the ideal time in the disease course to offer radiotherapy for Dupuytren's disease for the most optimal outcomes?
Radiotherapy is most effective when fibroblasts are actively proliferating, i.e., during the cellular or proliferative phase of the disease, when there is a palpable, progressive nodule or cord but no fixed contracture.Prospective German trials show that treating during this biologically active peri...
How do you approach perioperative management of anabolic therapies such as romosozumab and PTH analogues in patients undergoing joint replacement?
Although there is no good human data, there is some pre-clinical data that shows increased screw purchase in the setting of tptd use. It makes good common sense that an anabolic (both PTH types and romosozumab) would likely increase the purchase of an implant. In addition, if the patient had signifi...