Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In postmenopausal osteoporosis, would you switch to romosozumab (rather than a PTH/PTHrP analog) if a patient fractures while on denosumab?
This is an interesting question because it raises the subject of how one defines "treatment failure" among patients who are using bone-strengthening medications. I remind patients that our drugs are most effective at preventing spinal fractures with efficacy that can exceed 70% relative risk reducti...
Have you seen synovitis (even if subtle) with aromatase inhibitor musculoskeletal syndrome?
Aromatase inhibitor (AI) drugs have been associated with the onset of arthralgias and myalgias. These have been reported to occur in as many as half the women prescribed this class of drug. The onset of an inflammatory arthritis is far less common. There are selected case reports documenting the ons...
What are your thoughts on telitacicept use in SLE, and why has it not garnered more attention in US news cycle in rheumatology?
Telitacicept (a fully human TACI-Fc fusion protein that targets B lymphocyte stimulator (BLyS) and a proliferating-inducing ligand (APRIL) blocks the interaction of BLyS and APRIL, resulting in reduced B-cell proliferation and maturation. Theoretically, it makes sense that it should work in B-cell-d...
Would you stop methotrexate or leflunomide if MCV increases after starting the medication with no other parameters of anemia or leukopenia?
I would take this as a sign that the patient is taking their medication. Pretty common and definitely wouldn’t withhold RA tx for this.
What would be your approach to managing severe ANCA-associated vasculitis in a patient who is also septic from a bacterial infection?
It is prudent to evaluate if the ANCA-associated vasculitis is being triggered by the underlying bacterial infection. Certain clues on the kidney biopsy including diffuse exudative as well as diffuse crescentic [of same age] pattern of injury on light microscopy, intense C3 staining on immunofluores...
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 ...
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...