Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to management of pulmonary fibrosis in patients with a history of microscopic polyangiitis who do not have other active organ involvement?
ILD is an important organ manifestation in AAV, typically seen in patients with MPO-ANCA where ~20% of patients have ILD which often precedes the diagnosis of AAV. The most common radiographic pattern is UIP. ILD has been associated with a higher risk of mortality in AAV in multiple series including...
How do you approach management of osteoporosis in patients post lung transplant?
Osteoporosis in patients with lung transplants is essentially glucocorticoid-induced osteoporosis. Most patients with severe lung disease have a long history of glucocorticoid exposure. Post-transplant, these patients are often on long-term glucocorticoids. The primary pathophysiology of chronic glu...
How do you approach management of patients with psoriatic arthritis who have significant improvement in skin disease, but ongoing inflammatory arthritis despite multiple DMARDs and/or biologics?
Psoriatic arthritis is a heterogeneous disease and often the severity of MSK involvement and psoriasis are not well correlated. This is also true regarding treatment response. The approach to management in these cases depends on several factors:Psoriasis type and severity: If the patient has mild ps...
What is the typical work-up completed to rule out other conditions prior to making a diagnosis of fibromyalgia (other than history and physical exam)?
I agree with Don and will just add a few things. The workup to a large part depends on how long the person has had similar symptoms. In an individual who has had many regional pain conditions and lifelong issues with sleep, fatigue, or other symptoms of FM, there is very little work up needed. Howev...
How would you counsel a patient with systemic sclerosis who wants to consider microneedling on the face or other skin which is not clearly involved with scleroderma?
Microneedling is a cosmetic procedure that utilizes multiple small needles to create tiny holes in the skin that stimulate the skin’s own "healing process", which, entails the production of collagen and elastin. While regardless of the specific device used, it is considered a relatively safe procedu...
What is the utility of MRI for identifying disease activity in myositis patients when physical exam and labs are inconclusive?
Agree with @Dr. First Last, however, I want to caution about sensitivity and specificity of muscle MRI for a particular situation you are suggesting i.e., to evaluate if patient has active or inactive disease, has not been studied or proven. The muscle MRI, in general, has good sensitivity and speci...
How would you manage active psoriasis and psoriatic arthritis in patient on Rituximab and prednisone for MPO positive vasculitis?
The answer is it depends on several factors, the most important being how severe the psoriasis is and if the patient has axial involvement. Since the patient has failed or not responded to methotrexate or apremilast, adding these would not be an option here.While we do not have much data on combinat...
Would you offer lung SBRT for an individual with rheumatoid arthritis?
I wouldn't hesitate to use SBRT in this setting, all things being equal. The important caveats for "equal" are whether they have any component of interstitial lung disease. I'm very fortunate to have access to proton therapy, and about the only time I use it for SBRT lung is in patients with severe ...
Should methotrexate be categorically avoided in RA patients with COPD or RA-ILD?
Thanks for raising a very important question. It is something that every practicing Rheumatologist comes across several times during their career.The traditional teaching has always been to avoid using Methotrexate in patients with underlying pulmonary conditions due to the associated risk of Hypers...
Should MTX be avoided in RA patients with asymptomatic lung nodules?
It is well established that in some RA patients, methotrexate does cause accelerated nodulosis predominantly in the hands which improves after stopping the medication. That does not mean having pulmonary nodules is a contraindication to use methotrexate. I recommend doing frequent chest x-rays for m...