Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you favor obinutuzumab over voclosporin for patients with lupus nephritis and significant proteinuria and a history of non-adherence to medications?
Non-adherence to medications is a common issue in lupus patients, but this can be even more of a concern in lupus nephritis, where the pill burden for patients can be so high. I usually prefer to use intravenous medications for patients who have had difficulty adhering to oral medications in the pas...
How would you approach a patient with class III and V lupus nephritis, already on HCQ, MMF, voclosporin and losartan, but has continued proteinuria not yet attaining complete renal response?
Few things are more complicated than lupus nephritis, and this question is not answered easily. It depends on hematuria, Cr, proteinuria, C3, C4, dsDNA, and systemic symptoms. So, it depends on what I think is causing the incomplete clinical response. If I believe it is the class V lesion, I would g...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
Are the results of the SEAM-RA trial generalizable to other TNF inhibitors given the differences in immunogenicity?
This is a great question, and an important one because different TNF inhibitors have different immunogenicity and patients can make anti-drug antibodies that can effectively neutralize the drug and render it a less effective treatment option. This tends to happen more with some molecular constructs ...
Do you routinely recommend delaying dental extractions in patients who have recently received intravenous bisphosphonate therapy for osteoporosis treatment?
I don't because the risk of osteonecrosis of the jaw (ONJ) is very low.
How do you counsel patients with GCA on the benefits of steroids who have already experienced vision loss?
I first tell the patient they are at considerable risk for further visual loss in the same eye or the other eye over the next 1-2 weeks. I also let them know that, even though their risk of visual loss has been reduced, their best option for preventing further visual loss is immediately starting hig...
Would you start romosozumab in an active smoker?
This is not simple! But we are good at assessment of risk vs benefit (or benefit vs risk!)First I would reassess fracture risk, prior treatments, reason to consider romo. Then I would do a deep dive into risk assessment for cardiovascular disease: how much do they smoke, prior cardiovascular disease...
How soon after a fracture would it be safe to start anti-resorptive therapy?
This is an important question. There is no definitive answer, and there have been no clinical or preclinical studies that demonstrate delayed healing in the presence of bisphosphonates. Personally, I favor waiting a few weeks before we start. That also gives us time to do a proper metabolic workup. ...
How would you treat a patient with osteoarthritis of just one joint of the hand?
People do this in various ways - some people treat the joint with a large margin, others may treat the whole hand.I originally started by treating the affected joint, but pretty soon I after I switched and started treating the whole hand - pain is subjective and though it may appear localized, there...
How do you clinically and diagnostically distinguish stiff skin syndrome from scleroderma?
One other disease consideration that one should differentiate is diabetic cheiroarthropathy, or "diabetic stiff hand syndrome." These patients can see decreased extension of the digits (often referred to as "Prayer sign" changes) and thickening of the skin in the digits. This can be present in 50% o...