Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you manage arthritis resulting from deferiprone in transfusion dependent thalassemia?
The precise pathophysiology of deferiprone associated arthropathy is not well understood but some reports have suggested that there may be some deposition of iron in the synovial membranes, and some subchondral bone damage. Unfortunately, there is no specific treatment for this arthritis, other than...
In patients undergoing MRI evaluation for inflammatory back pain, how long do you recommend they hold NSAIDs prior to imaging?
The other issue regarding NSAIDs and MRI is whether these agents will suppress the bone marrow edema signal which has been demonstrated in some patients. Therefore, it is recommended to hold NSAIDs for at least 3 days prior to the MRI.
When do you start bisphosphonates empirically, irrespective of DEXA results, in patients going on chronic glucocorticoids?
I think this is an important question. I personally got really interested in bone in large part because of all the glucocorticoids that I was using to treat serious inflammatory diseases. I was fortunate to spend time with Dr. Howard Polley from Mayo when I was a fellow. He was on the team that gave...
Can romosozumab be used in patients on dialysis?
This is an interesting question given the common finding of osteoporosis among patients undergoing hemodialysis. There have been several individual case reports suggesting that treatment with romosozumab in this patient population can be safe and effective. The largest study (no control group) of wh...
What is your approach to practical monitoring of lupus disease activity in clinical practice?
ANSWER TO QUESTION 1:I am so glad I am being asked this question!I use my clinical assessment (or physician global assessment).I generally love the 2023 EULAR SLE management update (Fanouriakis et al., PMID 37827694). However, I disagree with their recommendation that clinicians monitor the SLEDAI (...
Do you hospitalize patients with newly diagnosed lupus nephritis and nephrotic syndrome if you are able to provide pulse steroids outpatient and follow them closely?
Usually not. I suspect it all depends upon one's ancillary support situation. We are able to do in-house labs, give immediate in-house IV pulse steroids, and I can call interventional radiology and get an ASAP renal biopsy. If there were complications, such as infection, thrombosis, need for dialysi...
What is your approach to severe discoid lupus refractory to conventional topical and systemic therapies?
Agree with Dr. @Dr. First Last's comprehensive answer regarding the treatment of refractory DLE. However, would add two biological options, Belilumab and anifrolumab. In fact, just now evaluated with a fellow a patient in Lupus clinic with refractory DLE to intralesional steroids, Chloroquine after ...
How do you approach management of patients with lupus and transverse myelitis not responding to pulse dose steroids?
I consider TM or longitudinal myelitis an emergency. I have been pretty aggressive in my treatment with this diagnosis, and have treated a case with pulse steroids, plex, and Cytoxan with excellent outcomes. The main challenge in such situations is differentiating overlapping MS or other autoimmune ...
Do you have a preference between Quantiferon Gold and T-spot TB for screening in patients starting immunosuppressive agents?
TSpot testing has better performance than Quantiferon Gold in patients with low lymphocyte levels, and/or on glucocorticoids (especially moderate to high doses). This is partially related to the way the essay is performed, and as such the Tspot is much less likely to result in an indeterminate or fa...
What is your initial treatment of choice in patients with RA and associated interstitial lung disease?
Because of the nature of the disease and to avoid unnecessary ILD treatment, it would not be appropriate to provide the 'direct answer' first. But the direct answer will appear in bold at the bottom. Of note, there is little data on therapeutics in RA-ILD. This is an important question because it hi...