Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Does your institution have formal policies or work flows to reduce unnecessary IGRAs ordered for patients on biologics?
We have developed a multi-specialty working group to implement this as a lot of unnecessary testing is getting done. This will include having a 2-3 question screening pre start of biologics, and then annually to asses risk, that we hope will be incorporated into the visit or an order set.
How would you manage a patient with symptomatic Paget’s disease and osteoporosis who developed new fragility fractures while on Fosamax?
This is a complicated patient, and symptomatic Paget's needs more information. But given one wants to treat the Paget's and there are fragility fractures I would give an injection of Zoledronic Acid (mostly for the Paget's) and if needed, start Romosozumab for the fragility fractures. However, I wou...
How would you approach a finding of osteoporosis (Z score -4.5) in a recently postpartum patient who had DEXA sent for long-term low-dose glucocorticoid use?
Ensure adequate calcium, vitamin D, and magnesium. I would check the PTH level and a 24-hour urine for calcium and creatinine.
How do you manage a patient with inclusion body myositis?
IBM is a slowly progressive disease with no proven treatment to date, unfortunately. The goals of care are to delay decline and maintain remaining muscle strength. The cornerstone of treatment is physical/occupational therapy. Blood flow restriction seems to anecdotally help some patients, pending t...
Do you use precision medicine tools (such as RNA testing, PRISM-RA) in clinical practice before starting a TNF inhibitor for RA?
Not using, as there is no sufficient evidence on using these tools yet.
How do you discuss sexual health with pediatric patients transitioning to adult rheumatology care when the patient is accompanied by parents or caregiver?
One of the most important aspects of transition is taking the time alone with the patient to ask questions confidentially. Best practice in pediatric rheumatology care is to have part of the clinic visit conducted with the patient alone- often, this is the opportunity to ask age relevant questions (...
What treatment options would you consider for a young patient with limited mobility, low bone mass and multiple vertebral compression fractures who is on dialysis for advanced kidney disease?
There are a lot of variables to this question. I would worry that the person may have a variant of OI (osteogenesis imperfecta) or some other collage problem and then add renal failure to the mix. I would try to establish the causes of each problem first such as steroid induced bone disease or a bon...
How do you approach long term management of glucocorticoid-induced osteoporosis in patients who develop osteonecrosis of the jaw on antiresorptive agent?
Osteonecrosis of the jaw is a rare complication of anti-resorptives with the exception of high doses used for cancer patients. Teriparatide (TPTD) has been anecdotally reported to assist in healing of ONJ. The patient described remains on glucocorticoids and is at very high risk for fracture, especi...
In patients with sicca symptoms and positive SSA/SSB how often do you perform other diagnostic testing such as salivary gland ultrasound, biopsy, Shirmers, ocular staining, stimulated salivary flow, etc?
In patients with sicca symptoms and positive SSA antibodies, I always try to confirm that they have objective evidence of dryness/gland involvement. This is because patients can say they have dry eye and/or dry mouth yet not have this bear out on objective testing (Bezzina et al., PMID 27992710, Rip...
Would you transition from denosumab to anabolic agents in patients who are in urgent need for extensive dental work?
From my experience, this is a catch-22. If you stop the Denosumab you will markedly increase osteoclastic activity throughout the entire skeleton which is why it is recommended that you not stop the medication without some other intervention. I have had several patients with either osteonecrosis of ...