Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you discuss harms of MGUS screening with other medical providers?
I understand the intent of the question, but - as always - real life is more complicated. I agree that the evidence for screening completely healthy patients for MGUS does not currently exist. But, for patients with unexplained pertinent lab/imaging findings or symptoms, it's not unreasonable. In th...
Do you repeat antiphospholipid antibody testing in a patient that previously met criteria for APLS?
I would repeat APL Ab testing if I am trying to risk stratify a patient in preparation for pregnancy or surgery, for example. In some cases (see a recently posted question about stopping anticoagulation in people with prior APLS history), I would also consider rechecking if I am thinking about disco...
Would you start anabolic agents for osteoporotic hip fracture healing?
There are two relatively well-done trials for tptd for fracture healing of the proximal femur. There was a Phase 3 trial for femoral neck fractures. The FDA made it quite complicated and demanded 2 separate trials of 1,200 patients each. The trials were 3 years in duration with many difficult outcom...
In patients with severe osteoarthritis, can elevated alkaline phosphatase levels be attributed to increased bone turnover from advanced joint degeneration?
Unlikely. Other potential sources require investigation. At the very least, explore alk phos fractions/isotopes, parathormone and vitamin D levels.
Do you recommend avoidance of occupational/environmental exposures in patients with pulmonary sarcoidosis?
The best assessment of occupational exposures associated with pulmonary sarcoidosis comes from A Case Controlled Etiologic Study of Sarcoidosis (ACESS). This is nicely summarized in a state-of-the-art article that lists occupations and exposures with both positive and negative associations between o...
Can anti-cardiolipin or anti-beta-2 glycoprotein antibodies cause prolonged PTT in the absence of a lupus anticoagulant?
Lupus anticoagulants are a heterogeneous group of antibodies that do not have uniform activity in all assays. Furthermore, testing procedures are not well-standardized. Since relevant clotting factor deficiencies have been ruled out and the long PTT does not correct with mixing, and since there is o...
Which fracture sites outside of the classical spine and hip are considered to be osteoporotic fractures even in the absence of a bone density diagnosis?
Any bone that sustains a fragility fracture can result from osteoporosis. The definition for fragility fracture is a broken bone that occurs after a low-energy trauma, such as a fall from standing height or less, or lifting something light. They are a type of pathologic fracture, which means they ha...
What is your approach when surgeons want to stop hydroxychloroquine prior to surgery?
I would absolutely say "do NOT stop HCQ." This is most likely a case of the surgical team mistaking HCQ for an immunosuppressant drug rather than an immunomodulatory drug. I would write a tactful "Rheumatologic Perioperative Recommendations" note where I would specifically state not to stop it and t...
How would you treat a perineural IgG4-RD with persistent paresthesia?
Perineuritis is an uncommon manifestation of IgG4-related disease (IgG4-RD), but it does occur. In most cases, this is an incidental finding that is not associated with symptoms or nerve dysfunction. This is most often observed in branches of the trigeminal nerve (e.g., infraorbital nerve, frequentl...
Do you recommend osteoporosis medication in postmenopausal females on anastrozole with very low Vitamin D (4.5)?
A vitamin D level of 4 is very low and should be corrected before any osteoporosis therapy is considered. Severe low D is associated with decreased Ca absorption and sometimes low serum Ca. Giving an anti-resorptive could result in hypocalcemia. Sometimes D levels that low are associated with muscul...