Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
What are best practices in management of severe acute infusion reaction from infliximab?
Severe infusion reactions to infliximab are not typically IgE-mediated. The presumption is that it is ‘anaphylactoid’ due to IgG antibodies directed against the mouse chimeric proteins in the molecule. Stopping the infusion is essential (at least temporarily) and administering antihistamines such as...
How do you approach the use of hydroxychloroquine in patients with a history of visual field defect from another cause such as macular degeneration or diabetic retinopathy?
As Dr. @Dr. First Last noted, close collaboration with an ophthalmologist is critical, as the findings of HCQ-toxicity on advanced imaging with modalities such as an OCT can often be distinguished from other causes, and hence there is not an absolute contraindication in most cases. A few considerati...
Is there any contraindication for use of Invisalign teeth aligners in patients undergoing treatment for osteoporosis?
I do not claim to be an expert in orthodontics (but I was married to an orthodontist for 20 years!). Tooth movement is somewhat complex and clearly involves both local inflammation and bone biology. The Invisalign-type device is relatively weak in terms of force on the teeth and is often reserved fo...
How do you approach CV risk assessment in RA patients when RA itself is associated with some degree of increased CV risk at baseline?
I try to screen for the CV risk factors, present or absent. If present, I use the CV risk calculator, as an example the online Framingham risk calculator, and multiply the risk by a factor of 1.5-2 as proposed by EULAR, depending on whether the RA is active or inactive. Once you have a good assessme...
Which myositis patients are good candidates for IVIG?
Good candidates for IVIG in myositis include any patient with refractory dermatomyositis, refractory necrotizing myopathy, anti-HMGCR antibody-positive patients, as well as patients with dysphagia, pregnancy, infection or malignancy. In general, it can be added to 1st-, 2nd- or 3rd-line treatment in...
How do you approach using DMARDs for patients with CPP arthritis who have frequent flares?
As far as I know, none of these agents are proven to prevent CPPD flares. Colchicine for acute flares. If someone is aware of evidence that any of these other choices work, I would be glad to hear about them. I have a patient with Gittleman's syndrome who had severe CPPD with almost constant flares....
When considering a biologic for seropositive RA after failure of methotrexate or triple therapy, do you consider using abatacept as a first line biologic or would prefer choosing TNFi?
Data is very limited on the superiority of one class of biologic drug versus another. The American College of Rheumatology and the European League Against Rheumatism do not mention bDMARD's preference for a first-line biologic in their respective guidelines for the management of RA. They do emphasiz...
Why are gout flares common in hospitalized patients undergoing diuresis but not commonly observed in cancer patients with hyperuricemia resulting from tumor lysis syndrome?
Tumor lysis syndrome (TLS) occurs with the release of uric acid, potassium, phosphorus and calcium into the bloodstream in response to cytolytic therapy administered in the setting of treatment for acute leukemia, B-cell lymphoma and rarely for solid neoplasms. Kidney injury results from the precipi...