Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to differentiating RA-ILD from medication toxicity (I.e. from methotrexate)?
RA-ILD occurs in about 7-10% of patient with RA. It is more common in males and in those with a history of smoking. Most are seropositive. The typical pattern on HRCT in 50-60% of RA-ILD patients is a UIP pattern followed by NSIP, OP, and even LIP is some cases. An experienced clinician with the hel...
What immunosuppressant will you choose in a patient with necrotizing myopathy partially responding to IV steroids and IVIG with a history of non Hodgkins lymphoma?
The decision should be taken in collaboration with the patient’s oncologist; however, Rituximab would be a reasonable choice to add given that IMNM generally responds well to it (particularly anti-SRP) and that it has a favorable safety profile concerning malignancy.
What is the clinical significance of a low titer RNP, negative Sm, but Sm/RNP that is very high titer?
Important question as I've seen clinicians incorrectly interpret anti-Sm-RNP as anti-Smith antibody.The different autoantibodies (RNP, Smith, Sm/RNP) react to different antigens as follows: Anti-RNP can react to multiple components (antigens) of the U1 small nuclear RNP particle (snRNP), Anti-Smith ...
How will you counsel patients regarding adverse effects of nemolizumab?
The adverse effect profile for this drug is minimal and the safety signals that were seen in higher amounts than placebo are what I would consider to be inconvenient and not worrisome issues.
How soon after starting treatment would you repeat imaging in patients with Takayasu to monitor response and ensure you have the correct diagnosis?
The optimal imaging frequency and imaging modality with which to monitor disease activity in TAK are not well defined. I would highlight some general concepts that I find helpful in determining the best monitoring strategy for a given patient. 1. Imaging interval should generally be shorter in patie...
How do you counsel patients on the risks and benefits of strontium supplements for osteoporosis management?
No experts whom I know prescribe Strontium for osteoporosis. It has not been shown to be efficacious to reduce fractures, although bone density will rise substantially. Also, bear in mind of very serious toxicities that have been associated with this drug. I would never use it in any of my patients....
How frequently do you monitor for hypocalcemia in patients on romosozumab?
I do not know the clinical safety data well. In my own practice, I never saw anybody get hypocalcemia. I assume the potential cause of hypocalcemia is the anti-resorptive effect of the drug. Before any osteoporosis drug. I get a good chemistry panel, PTH level, vitamin D level, and when appropriate ...
At what point would you consider anticoagulation in a pregnant patient with lupus nephritis and non-nephrotic range proteinuria?
If the patient does not have APS and does not have nephrotic range proteinuria, then the indication for presumptive anti-coagulation is unclear.
How do you approach treatment of RA with methotrexate in a patient with treated Hepatitis C and normal liver function?
Active hepatitis C infection can be present in the setting of normal liver function tests. So, I always check for the viral load, especially if the hep C treatment was done more than a few years ago. Here, the old alpha interferon-based treatments achieved a cure rate no better than 30%. The newer a...
How do you approach DMARD therapy in patients with rheumatoid arthritis and chronic hepatitis B?
Patients with hepatitis B core positivity, surface antigen positivity, and positive PCR for viral DNA, should be treated with entecavir prior to starting any DMARD. Given the DNA PCR is positive too, that indicates active viral replication and they may need treatment for a while before starting anyt...