Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach evaluation for underlying rheumatologic disease in patients with chronic asymptomatic thrombocytopenia?
APL testing as well as evaluation for SLE and Sjogrens with complement, urine, antibody testing, not just an ANA.
How do steroids and/or DMARDs affect biopsy results if a renal biopsy for suspected lupus nephritis is delayed?
In contrast to GCA/TA, where the Mayo clinic has published data that steroid treatment for as much as circa 2-4 weeks is unlikely to result in a false-negative biopsy, as long as accounts for the skip phenomenon and carefully examines multiple sections of the biopsy, I am unaware of similar informat...
How do you utilize methotrexate and/or hydroxychloroquine in the setting of limited scleroderma/CREST?
Thank you for this great question!The use of immune-suppression in systemic sclerosis is generally reserved for progressing skin sclerosis, progressive ILD, inflammatory arthritis, inflammatory myositis, and myocarditis. These manifestations have a significantly higher prevalence in diffuse cutaneou...
How often should you screen for lymphoma in patients with primary Sjogren's syndrome?
Depends on index of suspicion, I don't have a set schedule. In addition to assessing the initial "phenotype" and disease activity of SjD, I want to know baseline status of quantitative Ig's and if a monoclonal is present. I reassess based on clinical scenario over time. Some colleagues will recommen...
Do you delay pegloticase in a patient with an active gout flare?
I don’t. The patient should be on prophylactic colchicine (if their renal function allows), and part of their pre-treatment involves the systemic administration of corticosteroids anyway such as hydrocortisone (used in the initial drug trials) or methylprednisolone (Solu-Medrol). It is known that du...
How do you approach the evaluation of patients referred for chronic lyme disease and counsel patients regarding this entity?
"Chronic Lyme disease" is a term that needs careful definition before one can accurately evaluate and treat a patient. Is this chronic symptomatology with physical findings in a patient who actually had documented infection with B. burgdorferi in the past? Or are there no objective findings, no phys...
How would you approach management of a patient with a medium-to-large vessel vasculitis who developed perforation of the stomach and colon on steroids and cyclophosphamide?
The answer to this question is complex as will depend on the most likely option for the etiology of the perforation and the nature of the underlying vasculitis. If the perforation is felt to be because of vasculitic activity then the decision could be whether to continue the current therapy (not eno...
Should JAK inhibitors and anti-IL6 medications be avoided in patients with known diverticulosis?
The development of diverticulitis, including complications such as bowel perforation, has been reported in patients taking JAK and IL-6 inhibitors (for example, see here and here). As a result, a history of diverticulitis is a relative contraindication for these agents (and carry a “use with caution...
How do you manage patients with SLE undergoing assisted reproductive therapy with estrogenic effects?
For patients undergoing any form of assisted reproductive technology (ART), it is important to assess their SLE disease activity. If a patient has moderate to severe SLE disease, I recommend delaying ART until we have better control of their disease. Once we plan to move forward with ART, I check an...
Do you continue methotrexate in patients with inflammatory arthritis who develop non-melanomatous skin cancer while on therapy?
Data on methotrexate use and the increased risk of non-melanomatous skin cancers has been conflicting, suggesting an increased risk or a neutral risk. A recent case-control study published in the British Journal of Cancer (Polesie et al., PMID 36739322) did suggest an increased risk of both squamous...