Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you counsel and manage joint pain after isotretinoin treatment?
Firstly, if one starts with 0.5mg/kg joint symptoms rarely happen. My approach is to temporarily stop isotretinoin until symptoms pass and then start at half the previous dose and treat until clear. The ineffective dose was never found. We know now the critical factor in relapse is age-no matter wha...
Would you switch azathioprine to a different immunosuppressant if a controlled patient with SLE develops melanoma and/or non-melanoma skin cancer?
This is a difficult question with no definitive research-proven answer. Clearly, most of our drugs do enhance the chance of melanoma and nonmelanoma skin cancer. If one does a literature search the only one of our drugs that has not been reported to increase the chance for relapse of melanoma is Tac...
How would you approach evaluation and treatment of a patient on pembrolizumab therapy who presents with symmetric, proximal, upper extremity and lower extremity painful weakness without an elevated CK?
Pembrolizumab, like other checkpoint inhibitors, is associated with a number of immune mediated neuromuscular syndromes including GBS/CIDP, a myasthenic syndrome, and myositis. A patient with symmetric proximal weakness and normal CK could have any of the above conditions. Normal CK does not exclude...
How would you treat suspected secondary HLH in patients whom etoposide is contraindicated?
Thank you for the interesting question. It would be helpful to understand why etoposide is contraindicated. My general approach for these patients is to first ensure that there is no evidence of malignancy as a trigger as you do not want to mask that with steroids (I strongly recommend obtaining a P...
How do you manage calcium and vitamin D supplementation in patients with sarcoidosis on chronic steroids?
This is a great question with very limited data to help answer it well. The first-line therapy for sarcoidosis is corticosteroids, and chronic use can lead to decreased bone mass. Of course, Vitamin D supplementation is a very important factor in rebuilding bone mass. In sarcoid patients, this issue...
Is there any clinical benefit in referring patients with SLE or Sjogren's with cognitive impairment for neuropsychological testing?
I have been grappling with this issue more often in fibromyalgia and chronic fatigue syndrome and more recently in patients with Post-acute COVID Syndrome. In FM and CFS I have not found neuropsychological testing helpful to distinguish true cognitive impairment from the confounding effects of sever...
How do you approach the use of commercial testing such as AVISE CTD in clinical practice?
Short story to start off with: A little over 20 years ago, I was a young rheumatologist sitting in a meeting room full of more experienced rheumatologists from the Washington DC area. Some of them were very well known in the field. The person in charge asked, "anti-CCP antibodies are now available t...
How do you approach tapering immunosuppression in a patient with a history of Susac Syndrome who has stabilized on MMF and IVIG?
Susac's is a rare disease characterized by an occlusive retinal vasculopathy, eighth nerve disease including hearing loss and balance issues, and CNS disease with a predilection for involvement of the corpus callosum. I am not aware of any randomized controlled data to guide treatment for Susac's, b...
What is your approach to a patient with well-controlled seropositive RA on abatacept who develops melanoma?
There is evidence to suggest an association between the use of abatacept and melanoma. A recent multinational observational post-marketing study found that compared with other bDMARDs, exposure to abatacept in RA patients was only significantly associated with an increased risk of reporting melanoma...
How do you treat anti-HMGCoA myopathy?
IVIg is a great treatment for anti-HMGCoA antibody necrotizing myopathy. However, traditional treatments like methotrexate, azathioprine, as well as rituximab can be tried. We published a paper on IVIG results on refractory HMGCR and SRP positive patients with excellent results. Kocoloski et al., PM...