Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you use the peri-operative management of biologics and DMARDs guidelines, which were mainly based on total hip and knee replacement surgeries, for all peri-operative surgical management?
The American College of Rheumatology Perioperative Guidelines focused on patients undergoing hip or knee arthroplasty. These guidelines can be a helpful starting place when thinking about medication management in patients undergoing other surgeries, but my recommendations for perioperative managemen...
How do you approach the timing of DMARD initiation in patients with active RA who are on treatment for latent TB?
As the patient is already treated for latent TB, if they have not initiated DMARD therapy for RA, I would follow the guidelines and start conventional DMARD therapy. If the patient requires additional therapy because of insufficient response, I would choose a non-TNF inhibitor as the risk for TB rea...
Do you recommend avoidance of vaginal estrogen in patients with SLE?
It depends on the age. The SELENA study demonstrated that BCPs in premenopausal women did not lead to flares or increased disease activity though the risk of increased clotting is an issue for APL+ folks. Post-menopausal women treated with HRT had an increase in mild flares compared to those not on ...
For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?
Some recommendations call for completing a course of treatment for latent TB prior to starting a biologic but I find most patients and referring specialists are intolerant of that strategy. This reference: Yeo et al., European Respiratory Journal 2014 is a good example of data supporting a shorter w...
When is a biopsy necessary to diagnose relapsing polychondritis?
Since there are no specific lab tests for Relapsing Polychondritis, the diagnosis is based on clinical manifestations. Criteria proposed by McAdam et al. PMID 775252 require three or more of the following clinical features to confirm the diagnosis: Bilateral auricular chondritis Non-erosive, seroneg...
Do you consider immunosuppressive agents in progressive interstitial pneumonias or pneumonitis without a clear driving etiology?
Although it's often helpful to have a clear diagnosis of an underlying connective tissue disease (CTD) or positive autoantibodies to guide therapy (or perhaps feel better about prescribing it), we more often find ourselves dealing with ambiguous cases. When pathology is available to suggest an infla...
Do you recommend treatment of worsening skin thickening with Limited Scleroderma +ANA+centromere and if so with what agent would you use?
There really have not been adequate trials in patients with limited cutaneous scleroderma as far as the effectiveness of medication for 'worsening' skin thickening. In this situation, it is not clear since the patient likely has a long-standing disease, really has worse skin thickening and where is ...
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...
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...