Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to management of chronic recurrent parotitis in patients with Sjogren's Syndrome?
Uncommon, however, I consider chronic infection/reinfection, especially in setting of significant immunocompromise or severe dental/periodontal disease. Secretion from stensen duct os can be cultured.Salivary duct stones can be detected by ultrasound if ~ >2mm, and duct dilation seen.Especially if c...
What is your approach to a patient on long-term denosumab who now requires multiple invasive dental procedures?
This is an important issue and one our practice faces routinely. We have close to 2,000 patients on Prolia. When we initiate Prolia we discuss the concern about rapid bone loss associated with discontinuation. We advise that if they need a dental extraction we hope they can get it done before initia...
How do you manage diarrhea in a patient with CTD-ILD on MMF who was recently started on full dose nintedanib?
It is important to keep in mind that immunomodulator therapy is also frequently associated with gi toxicity (MMF, methotrexate, leflunomide, azathioprine, etc.). Given this, it is important to begin one therapy at a time in order to mitigate side effects and do understand which agent is responsible....
Do you delay spinal surgery (e.g. lumbar decompression for stenosis) in men or women with newly diagnosed osteoporosis and multiple thoracic compression fractures (not involving site of potential surgery) in order to initiate anabolic or anti-resorptive therapy to potentially improve surgical healing outcomes?
This is a fairly common clinical issue. Increasingly, spine surgeons are requesting anabolic bone medications prior to the type of surgery outlined in the question. Our approach has been to use three months of such treatment prior to the surgical procedure and then to continue that treatment after t...
Do you hold rituximab for cataract surgery?
I never stop any immunosuppressants for cataract surgery. The reason being, it may help prevent postoperative ocular eye inflammation (e.g. postoperative iritis). I learned this many years ago when one of my RA patients stopped their methotrexate and had a severe bout of new-onset iritis afterward. ...
Would you consider rituximab in a patient with severe GI dysmotility caused by scleroderma?
Severe GI dysmotility due to scleroderma remains refractory to most therapies. The rationale for recommending rituximab (RTX) in this setting is based on its use in rare cases of autoimmune gastrointestinal dysmotility syndrome (AGID) that appear to have a paraneoplastic basis. There are scattered c...
How would you approach management of a patient with checkpoint inhibitor induced psoriatic arthritis?
We will often try a short course of steroids if this is new psoriatic arthritis due to immune checkpoint inhibitor therapy. We then consider a DMARD like methotrexate or biologic. If biologics are needed, we will typically choose an IL-12/23 or IL-23 inhibitor or a TNF inhibitor.
Do you ever consider discontinuing hydroxychloroquine in patients with SLE in longstanding remission except in cases of overt toxicity?
I’ll assume that this question is only for SLE patients who are tolerating it well, have been in remission, and are not on steroids or other immunosuppressants (since hydroxychloroquine, HCQ, is safer than all of these).Since very few things in medicine are 100%, the answer must be “yes.” However, 9...
Can joint replacement surgery be performed in someone with active Paget’s disease elsewhere?
Joint replacement surgery can be done in patients with Paget's disease. There should be no problem particularly if the patient has been treated to suppress disease activity. The best treatment is a 5 mg intravenous infusion of Recast which can suppress disease activity for 5 years or more.
What else do you consider in the differential diagnosis for pulmonary-renal syndromes if there is low clinical and serologic evidence of AAV, Goodpasture's or other rheumatologic disease (SLE, RA, APS, Scleroderma)?
Endocarditis can mimic vasculitis and can have pulmonary hemorrhage. You CANNOT miss that one. Sarcoidosis is I suppose a pulmonary renal syndrome. Renal vein thrombosis from MGN with a pulmonary embolus is I suppose a pulmonary-renal syndrome.