Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What would be your approach to a patient with Scleroderma/Myositis overlap syndrome (+anti-Ku) and active inflammatory eye disease despite high dose mycophenolate?
This is a challenging question but impossible to answer without more information. Inflammatory eye disease includes uveitis, scleritis, corneal melt, and orbital inflammation. Just as scleroderma itself has a range of manifestations that drive the treatment, the various eye inflammations would requi...
What protective post-op measures do you recommend for a patient with scleroderma and a history of ILD, PH, Raynaud’s and digital ischemia undergoing cardiothoracic surgery?
Appropriate post-operative care in patients with scleroderma is very important. In the context of the cardiopulmonary disease, volume management is very important with close monitoring in I/O's to optimize fluid status. In a patient with a history of digital ischemia, it is important to keep the pat...
What would be your recommendation for treatment of worsening lung disease in a patient with long-standing scleroderma after long-term mycophenolate therapy which is no longer an option due to side effect/intolerance?
Someone who has been on long-term Mycophenolate for interstitial lung disease and has had stabilization or improvement in their lung function and then is unable to tolerate the medication may be able to be switched to mycophenolic acid sodium (myfortic) which is often less toxic and better able to b...
How do you approach medication management in patients with RA when transitioning from csDMARD triple therapy to anti-TNF?
There is not a one-size-fits-all approach to this question. Drug transitions can be influenced by several factors including individual side effects of medications, patient preference for other reasons, disease co-morbidities, ability to use prednisone as bridge therapy, etc. In general, hydroxychlor...
Would you stop azathioprine in a patient with ANCA vasculitis who has been in long term remission on azathioprine, but has a new diagnosis of lung cancer requiring initiation of immunotherapy?
Data about the effect of immunosuppression on the efficacy of immune checkpoint inhibitors suggests that there is a negative of effect of being on immunosuppression at the time of ICI initiation on tumor response. So if the patient really has been clinically stable for a long time there are a few op...
Have the results of the ancillary study of the VITAL trial, demonstrating that Vitamin D3 supplementation did not reduce the incident rate of fractures in generally healthy midlife and older adults, changed how you prescribe Vitamin D?
It should be appreciated that the function of vitamin D is to maintain a serum calcium concentration in a normal range to maintain neuromuscular function and most metabolic functions. It can accomplish this by increasing intestinal calcium absorption. When there is inadequate calcium in the diet, th...
Would you consider teriparatide use in a patient with prior radiation therapy, given that the black box warning regarding osteosarcoma risk has been removed by the FDA?
The rat studies were unequivocal that both teriparatide and abaloparatide increased the risk of osteosarcoma in rats given high doses for essentially their entire lifespan. Upon approval of teriparatide, Lilly agreed to a post-marketing pharmacovigilance study that started out as a case-finding stud...
How do you manage a DOAC if interested in testing for lupus anticoagulant?
Testing for anti-phospholipid antibodies encompasses two broad categories of testing. One is an ELISA based (aka solid phase) set of tests that include anti-cardiolipin and anti-beta 2 glycoprotein I antibodies. ELISA assay are not affected by DOACs. For the second lupus anticoagulant (aka fluid pha...
Is morphea, cutaneous scleroderma, with no organ involvement a contraindication for radiation in early stage breast cancer as part of breast conservation therapy?
I am not sure anyone can answer this question with a solid yes or no answer. The information we have about limited scleroderma and radiotherapy is for, lack of a better term, limited. We can draw from some experiences to guide the thought process. In one large series of patients from two scleroderm...
What is the recommended approach for systemic therapy in a patient with metastatic cutaneous squamous cell carcinoma with active autoimmune disease (dermatomyositis)?
Dermatomyositis can occur with myositis/myasthenia gravis (overlap syndrome). At the Ohio State University Comprehensive Cancer Center, we have established an Immunotoxicity Clinic headed by a rheumatologist, Dr. @Dr. First Last. I would recommend engaging with a rheumatologist who is familiar with ...