Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is the role of non-prednisone oral glucocorticoids in the management of systemic rheumatologic disease?
I saw this question and thought it was really interesting. I did some preliminary research on the topic and was amazed at how little is actually written in the scientific literature. Perhaps someone reading this can perform a search and offer some thoughts. I decided to write to start a dialogue on ...
Do you routinely use anti-resorptive medications in patients who have osteoporosis and longstanding hypoparathyroidism?
If a patient has hypoparathyroidism, I am unwilling to use bisphosphonates or denosumab because of fear of significant hypocalcemia. I will use other agents to treat their osteoporosis.
What is your approach to dosing and duration of rituximab for refractory lupus nephritis not responsive to cyclophosphamide or mycophenolate?
FirstThe question specifically states "not responsive." It would be highly improbable not to have some improvement with these therapies in conjunction with using hydroxychloroquine (HCQ), steroids, ACE inhibitors, ARBs, and sodium-glucose cotransporter 2 (SGLT2) inhibitors in an adherent patient.Wha...
What is your approach to tapering therapy in patients with pulmonary sarcoidosis who are asymptomatic with stable pulmonary function and imaging?
We generally do not use weight-based dosing for treating sarcoidosis but often will use 20 mg daily (0.25 mg/kg) as a starting point. If a patient is newly started on prednisone, then we may use a gradual taper 20 mg daily for 1 month, then 15 mg daily for 1 month, then 10 mg daily until they are re...
Do you recommend a particular antiresorptive/anabolic agent for patients who are at high risk for fractures but have high risk of osteonecrosis of the jaw?
Teriparatide has improved bone healing in patients with osteonecrosis of the jaw, so would be a good choice for patients at high risk of ONJ.
What are your practice recommendations regarding live vaccinations in infants/children of women who are currently on DMARDs and are breastfeeding?
This question needs some clarification to provide an exact answer. However, in regards to DMARDs in lactation, per the ACR 2020 Reproductive Health Guidelines and resources like LactMed and Mother to Baby (both free!), Methotrexate, Leflunomide, and Mycophenolate are not recommended in lactation. Th...
Excluding CLL, in which patients would you screen for hypogammaglobulinemia?
Patients I screen for hypogammaglobulinemia include those with: gammaglobulin gap (total protein-albumin) less than two; advanced multiple myeloma or mantle cell lymphoma; patients who have received CAR T cells or bispecific antibodies against BCMA or CD20.
What's the best treatment for calcinosis universalis in a scleroderma patient?
This is a very challenging question since there is no standardized approach to the management of calcinosis. Calcinosis Universalis describes extensive calcific deposits with expanded bands or sheets of calcification seen mainly in juvenile dermatomyositis. In scleroderma, the calcific deposits are ...
What's the best approach for severe calcinosis cutis in a patient with dermatomyositis who is unresponsive to diltiazem and colchicine?
Calcinosis cutis remains one of the most frustrating, typically recalcitrant manifestations of DM for both patients and physicians.Like Dr.@Dr. First Last, I also find that while there have been multiple case reports or small trials of various regimens published, the disappointing real-world variabi...
How do you approach medication management in biopsy-proven pulmonary sarcoidosis with disease stable for over 2 years on hydroxychloroquine and low dose prednisone?
Well articulated by a card-carrying rheumatologist! I agree completely with Dr. @Dr. First Last’s commentary and would like to add some additional thoughts and observations. Steroid requirements can be, in fact, viewed as a biomarker of disease. If a patient is found to require even low-dose predni...