Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you still consider the use of pegloticase in someone with substantial tophaceous burden despite optimal uric acid levels?
If a patient has a significant burden of tophaceous deposits causing functional impairment despite serum uric acid control achieved through oral uric acid lowering therapy (ULT), I strongly recommend considering a course of enzymatic therapy with pegloticase. Terms such as “treatment failure gout” o...
What is your approach to dental prophylaxis for patients on biologics?
My approach has been to not recommend antibiotics prior to routine dental care for patients on biologic therapy. I'm not aware of any compelling evidence or guidelines supporting preventive antibiotic treatment for such patients. Of course, there may be exceptions to this. Antibiotic prophylaxis mig...
How do you approach management in patients with adult-onset Still’s disease presenting with active polyarthritis (without macrophage activation syndrome) who remain symptomatic despite prednisone 15 mg/day and methotrexate 25 mg/week?
Biologics, especially IL-1 but also IL-6 blockers, have been shown to be beneficial for patients with Still's disease. In fact, there seems to be a window of opportunity whereby patients that are started early on cytokine blockade are more likely to achieve drug-free remission in the future. Anakinr...
Would you check ANCA titers in a patient with a history of PR-3-ANCA glomerulonephritis in remission and a stable creatinine but with recurrent microscopic hematuria?
Not sure there is an easy answer to this. A patient in remission should not get a recurrence of glomerular hematuria unless the disease is active. A new onset glomerular hematuria would certainly make me worried about a relapse, some of which may be subtle, indicating "grumbling disease". The data o...
Do you routinely perform muscle biopsies in patients presenting with the classic symptoms of Inclusion Body Myositis along with positive CN1A antibody?
YES. There are new consensus guidelines from ENMC about the diagnosis of IBM (Lilleker et al., PMID 38522330). They define the clinical presentation of IBM as typical (age >45, progression over >12 months, long finger flexor weakness > deltoid weakness, quadriceps weakness > hip flexors), or atypica...
Would you recommend waiting for a low Vitamin D level to correct to goal prior to giving a scheduled Prolia injection when transitioning a patient from Zolendronic acid to Prolia therapy for worsening osteoporosis?
When ZA is in its early days patients had to have a D level of 15ng/ml. To be on the safe side most of us want a 25 ng/ml level which is easy to obtain.
What is your experience with using anabolic therapy for treatment of osteoporosis in patients with EtOH cirrhosis and is one agent preferred over another (PTH analogue vs Evenity)?
The approach that has been recommended may be reasonable. It is important to recognize that a bone density score consistent with osteoporosis does not necessarily mean that the patient has osteoporosis i.e. loss of mineral and matrix. Osteomalacia, a mineralization defect of the collagen elastin mat...
Are SGLT2 inhibitors contraindicated in patients with osteoporosis and history of vertebral and hip fractures?
In ovariectomized mice, the GLP-1 agonists were found to improve bone density by reducing the inflammation in the bone marrow so there is no contra-indication for a patient with osteoporosis and vertebral fractures to take this class of medications. It is the first weight loss therapy that is not as...
What is the stepwise investigation of patients suspected of inflammatory myopathy?
I have published an algorithmic approach to suspected inflammatory myopathy in Continuum Lifelong Learning in Neurology from AAN (Manousakis, PMID 36537973). Unfortunately, the article is not free, and I can't attach the algorithm in this response, because it's a PPT file. Happy to provide it upon r...
Would you add abatacept to treat active inflammatory arthritis in a patient with history of RA-ILD who is already taking mycophenolate?
Although there are no controlled trials of abatacept in RA-ILD, the current literature suggests a stabilization of ILD in RA patients and is one of my principal go-to agents for this situation. A review paper from 2021 (Vicente-Rabaneda et al., PMID 33887489) indicated abatacept was associated with ...