Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is chronic methotrexate for rheumatoid arthritis a contraindication for prostate brachytherapy?
I would agree with Dr Rogers that there is really limited information with in the published literature to guide us in this specific clinical situation. In my personal experience I have recommended holding the methotrexate (if possible) prior to a planned course of external beam radiotherapy, HDR bra...
Should methotrexate be stopped prior to radiation therapy if a patient has rheumatoid arthritis?
I have not stopped as dose of MTX for RA is low (7.5 mg) and there is data of CMF with RT for breast cancer with higher dose of MTX showing no significant increase in morbidity.
What is your approach to management of patients with recurrent nephrolithiasis and osteoporosis who are receiving teriparatide?
Bones and calcium containing kidney stones can interact. I find it interesting that patients who have primary hyperparathyroidism are prone to predominantly calcium phosphate kidney stones, since the action of parathyroid hormone on renal tubes is to reabsorb urine calcium. That’s why people with hy...
How do you treat multisystem sarcoidosis refractory to methotrexate, humira, and remicade?
There are many layers to this question because there are many possible explanations for treatment failure. The first issue to consider is whether the specific features of sarcoidosis being treated are best addressed through an immunosuppressive approach. Some manifestations of sarcoidosis may be ind...
Would you consider the use of an anabolic agent to promote fracture healing?
While there are no drugs FDA that are approved to enhance fracture healing, there is considerable literature and experience using the PTH-based anabolic drugs to attempt to heal a fracture. They are sometimes used in the setting of delayed union or non-union. They have been used in elite athletes to...
When would you suspect metabolic myopathy and what is your approach to initial workup?
Great question and really important to rheumatology practice. As always, a history and physical exam is the best initial diagnostic tool. It’s a little bit difficult because of the sheer number and heterogeneity of non-autoimmune myopathies that clinicians may encounter, but a few general principles...
Do you send CSF or serum ACE levels in the workup of neurosarcoidosis?
Unfortunately, serum and/or CSF ACE levels are just not sensitive or specific enough to guide the diagnosis or treatment of sarcoidosis, particularly neurosarcoid. Rather, imaging characteristics, specific organ system involvement, and biopsy results are much more useful in my practice.Bradshaw et a...
Can you use leflunomide and rituximab in a patient with both multiple sclerosis and rheumatoid arthritis?
It is rare for a patient to have both diseases, but immunosuppressive therapy can be used for the management of both conditions. A study published in 2021 investigated the use of a combination of rituximab and leflunomide in rheumatoid arthritis (Behrens et al., PMID 33738492). Rituximab has previou...
What is your approach to managing osteoporosis in patients with end stage kidney disease?
I don't believe you can make a diagnosis of osteoporosis in patients with ESRD. They have to be treated based on the disorders associated with CKD-MBD and not solely based on the results of a bone density scan. In some patients with documented low turnover disease and mineralization defect, some may...
When have you found Dual-Energy CT most useful in evaluating for gout?
I agree with Dr. @Dr. First Last, one rarely needs DECT scanning to establish a gout-related diagnosis, though, under unusual circumstances, it may be very helpful. DECT scanning is a highly sensitive technology in identifying tophaceous deposits and quantifying their extent and volume. First descri...