Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In a patient with active spondylarthritis and uveitis who cannot take TNF inhibitors, what is your next agent of choice?
Uveitis and typically acute anterior uveitis is commonly associated with Axial spondyloarthritides (SpA) but also other spondyloarthritides and is usually recurrent with exacerbation and resolution. The approach to the management of uveitis in my opinion is similar to patients without an underlying ...
How do you approach choosing between subcutaneous and IV actemra for RA?
This question has been studied using data collected by eight European RA registries. The aim of the study was to compare the proportions of patients achieving Clinical Disease Activity Index (CDAI) remission and low disease activity (LDA) at 1 year. There were no statistical differences observed and...
How would you approach a patient with anti-scl70 ab positive sine scleroderma complicated by ILD who also has seropositive RA with active arthritis?
This scenario can be looked at in different ways. For example, does this patient have scleroderma that explains the ILD and seropositive RA to explain the arthritis? Or, does this patient have seropositive RA which explains both the arthritis and the ILD? I favor the latter explanation. In this scen...
Is history of radiation an absolute contraindication to using parathyroid hormone (PTH) analogues?
Hx of prior radiation was never a contraindication, it was a warning due to the known increase in osteosarcoma in patients who had prior radiation. A contraindication requires proof of harm. There was no data that radiation plus a PTH anabolic increased the risk of osteosarcoma. With the review of 1...
How do you approach use of DMARDs and/or biologics for inflammatory arthritis in patients with a history of seizure disorder on anti-epileptic medications?
Polypharmacy should always be a worry in our treatment of rheumatoid arthritis. Fortunately, the biologics, reflecting their immunoglobulin framework, are rarely a concern for drug-drug interactions. This is in contrast to small molecule inhibitors such as methotrexate, leflunomide, and the jak inhi...
Are you comfortable with using NSAIDs in a patient on methotrexate for inflammatory arthritis?
Yes, there is a theoretical drug-drug interaction here. However, I don’t avoid using the combination altogether. In certain patients, I am still using NSAIDs in combination with MTX. However, not uncommonly, the patient’s pharmacist may warn the patient of this potential interaction, and they would ...
Do you continue TNF inhibitors in patients with a new diagnosis of CLL?
If the patient does not require any treatments for CLL that are potentially immunosuppressive, I would continue TNF-inhibitor therapy in this setting. It is always helpful to discuss the case with the patient's hematologist/oncologist to make sure everyone is comfortable with the plan.
How do you approach peri-operative management of anti-resorptive therapies such as denosumab in patients undergoing joint replacement?
This is a very practical question. I think it is fine to continue the denosumab on a regular 6-month schedule for patients undergoing joint replacement. The reduction in bone turnover should not affect the implant. In fact, with denosumab, there is a small anabolic effect with each treatment that mi...
How do you approach recurrent migratory superficial thrombophlebitis in a patient with a negative malignancy workup and low-titer anticardiolipin antibodies?
With anticoagulation using a DOAC.
How do you approach a patient with Paget’s disease of bone with elevated alkaline phosphatase and history of chronic kidney disease?
You can give Zol IV, which is clearly the optimal treatment for active Paget's. Those in the field that treat many such patients just administer this very slowly over 1-2 hours and assure good hydration concomitantly. I have treated a number of patients like this, with this scenario, without any pro...