Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach RA management in a patient who develops a new solid tumor while on therapy?
Risk-benefit ratios need to be individually assessed. There are several aspects to take into account: Choice of DMARD - Data on impact of various DMARDS on cancer recurrence or progression is scarce, especially for patients with active cancer. In general, there are few concerns for conventional DMA...
How do you approach treatment of a patient with active RA and a history of Lynch Syndrome?
The presence of hereditary polyposis coli and its predisposition to colon cancer should have little effect on the management of RA. Available data indicate that methotrexate has at best a neutral effect on predisposition to malignancy. There are data to suggest that the combination of methotrexate a...
Do you recommend genetic screening for FMF in asymptomatic first-degree relatives with a strong family history (multiple family members, severe/refractory disease)?
In the absence of FMF symptoms, it is not necessary to obtain genetics in first-degree relatives of patients with FMF. More critical than genetics is to screen for systemic inflammation and amyloidosis, which I would consider doing. I would check inflammatory markers and urinalysis with urine protei...
Do you restrict topical diclofenac use in your patients with chronic kidney disease?
It is a great question. I normally don't but I always do it with a touch of hesitation. I believe the absorption is minimal but it also depends of the degree of use. At this time, when narcotics are in restricted use and oral NSAIDs are not a good option in patients with CKD, topical NSAIDs may be t...
Do you recommend adjusted adult cancer screening for patients who have been on long term biologics and/or tsDMARDs since childhood?
I recommend routine adult cancer screening with the exception that I suggest annual dermatology evaluation for patients who are taking chronic immunosuppression.
What is your approach in differentiating IPAF (interstitial pneumonia with autoimmune features) versus "CTD ILD" in patients with serologic abnormalities but do not fulfill criteria for autoimmune disease?
Even for those of us who work in ILD clinics, this can be a challenging issue. The concept of IPAF (interstitial pneumonia with autoimmune features) was developed in 2015 jointly by the ATS and the ERS for study purposes and as such is somewhat helpful in the clinic. Much like classification criteri...
Does synovial biopsy provide diagnostic value in undifferentiated inflammatory arthritis?
Currently, a synovial biopsy cannot reliably distinguish undifferentiated inflammatory arthritis. Work on this topic is ongoing, and there is reason to hope that biopsy findings may someday provide useful information regarding the pathology and treatment of various types of arthritis.Donlin et al., ...
When do you recommend using trabecular bone score (TBS) for managing osteoporosis?
Trabecular bone score is a valuable tool in the evaluation of osteoporosis and risk of fracture. It is an indirect indicator of bone microarchitecture. Although TBS predicts fracture risk, it should not be used alone but in conjunction with BMD for deciding whether to treat the osteoporosis and if s...
How do you approach follow up of young patients with isolated +ANA, but no current clinical signs or symptoms of SLE?
An old study showed that ANA can be positive in patients who develop lupus up to 9 years (average 3 years) before the onset of clinical disease but it was not necessarily isolated ANA as Ro and La antibodies could also be detected long before the onset of the disease (Arbuckle et al., PMID 14561795)...
In the treatment of lupus nephritis, which patients may benefit from the use of rituximab or other B-cell depleting agents during induction?
I agree with @Dr. @Dr. First Last's previous answer (posted July 2020). In addition, the 2024 ACR Lupus Nephritis guidelines (discussed at the 2024 ACR meeting) still recommend mycophenolate (MMF) or cyclophosphamide as first-line induction therapies for lupus nephritis (LN), rather than B-cell depl...