Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?
Nonbacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks endocarditis, is a form of endocarditis characterized by the presence of sterile vegetations on cardiac valves. It is most commonly associated with systemic autoimmune conditions, notably systemic lupus erythematosus (SLE) and a...
When is it appropriate to refer a systemic sclerosis patient for bone marrow transplant evaluation?
I consider patients for referral who have early diffuse disease who have continued to progress despite standard of care therapies. I think some would argue that this may also be appropriate for early patients as first line therapy if they have high risk features for progression, but I typically will...
How do you approach sequentially tapering combination therapy (i.e., IVIG, mycophenolate, rituximab) for dermatomyositis that is in remission?
This process involves trial and error and requires collaboration between the physician and the patient to determine the most appropriate tapering strategy. My personal preference is to begin tapering medications with the highest risk of side effects. Among IVIG, mycophenolate, and rituximab, I would...
Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?
Liver elastography is a useful tool to use when assessing the potential hepatotoxicity of various drug therapies. Traditionally, methotrexate accounted for nearly all the hepatotoxicity issues that we faced; however, we can add many other drugs to that list. Virtually, every immune suppressive drug ...
What treatment regimen would you recommend for a patient with biopsy-proven giant cell arteritis and diffuse cutaneous systemic sclerosis?
This is a challenging situation in which you must weigh the well-known high risk of irreversible blindness in untreated GCA with the known increased risk (but not necessarily 100% risk) of scleroderma renal crisis with steroid exposure >=15mg (Steen and Medsger, PMID 9751093). It is important to und...
How long are cholinergic agonists such as pilocarpine required to be held before doing tear assessments (ocular scoring and Schirmer’s) and sialography/salivary collection?
Discussed this with ocular and oral colleagues in the Berkeley Sjogren's Clinic. Neither request patients be off secretagogues before testing. If the testing is normal, and there is a reason to retest, they will ask the patient to hold the medication for 12-24 hours. Ocular expert did not see much e...
Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?
The landscape of FUO and IUO and our clinical approach to diagnosing its cause has changed significantly over the past several decades. More sensitive microbiologic screening for infectious etiologies, including syndromic molecular panels and next-generation sequencing are now clinically available a...
What is your approach to discordant dsDNA testing, such as positivity to dsDNA by crithidia but negativity to dsDNA by other modalities?
What a great question with many facets. The information I provide is meant to be very practical. These answers are from the viewpoint of a rheumatologist and not an immunologist. I discussed this subject with Dr. Debra Zack, a rheumatologist/immunologist who is an expert with anti-dsDNA, and I had t...
Do you assess baseline salivary gland function before starting treatment in patients with Sjogren's syndrome?
No. Visual assessment of salivary pool and oral mucosa is routinely done. In the initial consultation and management plan, most always, referral to Sjogren's Oral Medicine Specialist is made where whole salivary flow is measured, usually by Unstimulated Whole Salivary Flow Rate (abnormal, less than/...
When considering the use of DOACs in APLS, does the number of positive APLS antibodies influence your decision?
The number of antibodies is an important consideration.On the one end of the spectrum, I would not recommend any DOACs in a triple positive APLS (especially with arterial thrombosis). Having said that, I would not change treatment in a triple positive APLS patient if they were started on DOACs in th...