Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you have a patient temporarily discontinue methotrexate while receiving a FAST or FAST FORWARD regimen for breast irradiation?
I favor continuing as the dose of MTX is low for RA and in CMF era with much higher methotrexate dose, RT plus MTX was well tolerated.
What do you recommend for fertility preservation in pediatric patients with impending cyclophosphamide use for treatment of a rheumatic disease?
Cyclophosphamide (CYC) is an alkylating agent primarily used in the treatment of malignant lymphomas, and its gonadotoxic properties are well-established. CYC can cause ovarian toxicity via follicle atresia and granulosa cell apoptosis in females as well as oligospermia and azoospermia in males. In ...
How do you approach the timing of Rituximab during pregnancy in a patient with life or organ threatening autoimmune disease?
The short answer is that I give it whenever it is needed for organ or life-threatening disease. Giving it earlier in pregnancy may have less impact on the fetus/neonate. In general, we all try to avoid routine treatment with rituximab during pregnancy due to the expected placental transfer after the...
What is your approach to a patient with a low alkaline phosphatase?
This is a wonderful and increasingly relevant question as it is not uncommon for someone to have a low alkaline phosphatase and be told it is not important since alkaline phosphatase is only important if it is elevated. Causes for this abnormality include protein deficiency, Wilson’s disease, and hy...
Do you generally recommend starting nintedanib prior to immunosuppressive therapy in a patient with CTD-ILD?
Patients with autoimmune disease-associated ILDs such as those with rheumatoid arthritis-related ILD, Sjogren and inflammatory myositis-related ILD are usually on background DMARD/immunosuppressive therapy already at the time the ILD is detected. These therapies are also important in helping to redu...
How do you decide whether to continue hydroxychloroquine in a young patient who develops subretinal neovascularization with no other risk factors?
Hydroxychloroquine (HCQ), an anti-inflammatory and immunomodulatory agent, is used to treat autoimmune diseases (rheumatoid arthritis, lupus, Sjogren’s disease, etc.) and malarial prophylaxis. Vision problems can ensue resulting from these deleterious irreversible effects of HCQ on retina if the cum...
How long do you recommend that a patient wear a mask when resuming biologic infusions following a recent upper respiratory infection?
Patients who have acquired an upper respiratory tract infection in the COVID, RSV, influenza era should wear masks as long as they are deemed contagious. The CDC makes recommendations concerning the duration of masking and the type to use. For COVID the current suggestion is 10 days after the cessat...
What is your approach to tapering chronic steroids in patients who are at high risk of HPA suppression?
There are rare cases when the adrenal function never seems to recover. The ACTH recovery happens before cortisol so that it can be monitored as a marker. When I get a consult about tapering GCs in a patient on long-term therapy, I usually let the primary team (e.g., rheumatologist) cut back on predn...
How do you think about biologic use in patients with underlying HIV infection?
This is always a difficult problem, and a tough clinical call. However, over the years of seeing these people, I have come to realize that following their viral load and CD4 counts while looking for immunologic recovery allows us as Rheumatologists a lot of opportunities to treat. While I have class...
Can anabolic agents be used in a patient with history of radioactive iodine treatment for hyperthyroidism?
This is an interesting question. When PTH was approved it had a black box warning for patients who had a history of radiation to the skeleton due to risk of potential osteosarcomas. The black box has been removed for the duration of use. Since we have another anabolic agent without that black box, I...