Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In a patient with isolated HLA B27+ anterior uveitis, how long would you continue immunosuppressive therapy?
Although the majority of patients with Human Leukocyte Antigen B27 (HLA B27)-associated recurrent, acute anterior uveitis have some evidence of spondyloarthropathy, this disease does occur sometimes with clinical disease only in the eye. The disease is not usually chronic (i.e., lasting longer than ...
How do you approach the management of recurrent episcleritis in a patient with RA that is otherwise well-controlled?
The episclera lies on top of the sclera. The majority of patients with episcleritis do not have a systemic disease, although patients with rheumatoid arthritis are more prone to develop episcleritis. Episcleritis must be distinguished from scleritis, which is also associated with rheumatoid arthrit...
Would you consider using a JAK inhibitor for a patient with RA associated scleritis?
Yes, I have used it before with success when with limited options. I recommend speaking to the MSL from one of the JAKi developers and they can provide the data to make an informed decision or to appeal to insurance if denied.
What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?
This is an interesting clinical scenario. It highlights some of the current issues we face as rheumatologists, namely an atypical presentation of one of our more common diseases. This patient is labeled as having seropositive rheumatoid arthritis yet lacks arthritis features. I suspect the diagnosis...
Would you avoid combining JAK inhibitors with IVIG given the risk of thromboembolism?
The evidence for this is not very clear and limited. I think a honest discussion about the risk of JAKs and IVIG with the patient will be the most important; but as long as there is no clotting history or high risk of DVTs/PEs, and this is documented, and if a patient needs both medications to attai...
Do you always pursue testing for NOD2 mutations when you are suspecting a diagnosis of Blau syndrome?
Blau Syndrome is a rare, autosomal dominant disease caused by mutations in the NOD2 gene, which codes for an intracellular sensor for muramyl dipeptide which is present in bacterial cell walls. The classic triad is arthritis, uveitis, dermatitis, but other organs can be affected. I do think that any...
Do you always biopsy patients who present with classic skin findings of dermatomyositis?
I actually very rarely perform a skin biopsy to confirm dermatomyositis, much like I rarely biopsy classic psoriasis or classic eczema. Because I see dermatomyositis frequently enough in my practice, most times, I can confidently diagnose it by physical examination alone. I reserve performing skin b...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
How do you taper corticotropin injections (Acthar) in patients with rheumatologic disease?
All rheumatologists will at some point in their career have a patient or two or three who do not tolerate any of the usually available steroids (po prednisone, po methylprednisolone, triamcinolone IM, IM methylprednisolone/dexamethasone, IV methylprednisolone) and who have ongoing active inflammator...
How do you counsel patients on the risks and benefits of an IL-23 agent versus an IL-17A or IL-17A/F agent?
Both IL-17 and IL-23 agents have demonstrated excellent efficacy for psoriasis. Choosing between them often comes down to access and insurance coverage.With that being said, considerations include: Side effect profile: The side effect profile for both IL-23 and IL-17 agents is similar, with the exc...