Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
How do you counsel patients on the use of topical nitroglycerin for Raynaud's?
I am actually not a big fan of topical NTG for Raynaud phenomenon. We know that there is some significant systemic absorption and patients may have high rates of side effects (such as headache). These rates were as high as 30% in some of the studies, which I think is higher than we see with use of o...
Is there any evidence regarding bone density gains/fracture reduction in the setting of treatment with romosozumab after a two year course of teriparatide?
There was a study by Ebina et al., PMID 34020048 titled "To investigate the effects of prior treatment and determine the predictors of a 12-month treatment response of romosozumab (ROMO) in 148 patients with postmenopausal osteoporosis".This study was a prospective, observational, and multicenter st...
How do you approach ongoing screening for TB in patients with a history of treated latent TB, but who have ongoing use of DMARDs and/or biologics given Quantiferon testing and PPD can remain positive?
Interferon-release assays (such as Quantiferon) and PPD testing do not discriminate between infection, reinfection, and prior infection with TB. However, in most developed countries, the likelihood that a patient who has once been treated for LTBI becomes reinfected and develops LTBI again is low, i...
How do you approach discussing the pill burden of voclosporin with patients who already have to take a regimen such as MMF+HCQ+ACEi and possibly more?
Medication adherence and a chronic disease such as lupus is an issue regardless of the number of medications. For example, hydroxychloroquine is very effective, but studies often show poor adherence as measured blood levels may be undetectable or below the intended therapeutic target.For patients wi...
In what cases, if any, do you find the use of naltrexone to augment lifestyle interventions (i.e., cognitive behavioral therapy, graded exercise therapy) for chronic fatigue to be helpful?
Absolutely no.
What is your approach to managing pyoderma gangrenosum recalcitrant to oral steroids?
Pyoderma gangrenosum is notoriously difficult to treat. The first thing I'd recommend in a case refractory to steroids is to reconsider the diagnosis. Notably, a high percentage of PG is misdiagnosed, so lack of response may indicate that you are dealing with a mimicker (e.g., infection, neoplasm, v...