Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What criteria do you use on echocardiogram and PFT to determine who needs further evaluation for CTD-associated pulmonary hypertension?
PFTs are often obtained in patients with systemic sclerosis to evaluate for interstitial lung disease. Low DLCO on PFTs can signify an increased probability of PH, but it is by no means specific. Echocardiograms are readily available, offer additional information about possible causes of PH (e.g. LV...
Do you counsel your patients on the potential decreased effectiveness of oral contraceptives while on Sarilumab?
As someone who focuses on reproductive health, I personally don't counsel on this. From professional drugs interaction resource: "Plasma concentrations of drugs that are CYP450 substrates may decrease following the initiation of interleukin (IL) inhibitors, tumor necrosis factor (TNF) blockers, or i...
What are magic mouthwash alternatives that you would recommend?
Many of our patients will make their own DIY MMW per Phil's My Pharmacist (YouTube) instructions -- uses benzocaine/Cepacol lozenges -- they say it's much more effective than the compounded one from the pharmacy. It is also more economical.If the majority of bothersome mucositis is in the oral cavit...
How would you approach the treatment of checkpoint-inhibitor-mediated temporal arteritis?
Temporal arteritis or GCA is a rare immune related adverse event due to immune checkpoint inhibitor (ICI) therapy. Corticosteroids are the first line treatment, along with holding the ICI. As there have been limited cases, there is not evidence for IVIG in this setting.
How does the presence of nonalcoholic fatty liver disease (NAFLD) impact your choice of csDMARD for RA?
Excellent question and one that comes up often in practice. For the sake of discussion, let's assume hepatitis B and C serologies are negative and there is no suspicion of viral hepatitis. The presence of NAFLD has a direct impact on my choice of csDMARD for RA in this way: if there is significant l...
Are there certain subsets of ANCA vasculitis patients for whom you would consider life long maintenance therapy?
Overall the field is moving towards longer, and sometimes indefinite maintenance therapy. This is because multiple studies have demonstrated that relapse risk increases when maintenance therapy is stopped. I consider indefinite maintenance therapy for the following patients: 1. Frequent relapsers - ...
How would you manage a patient with antiphospholipid syndrome in the setting of severe steroid-refractory thrombocytopenia?
Dr. @Dr. First Last answered the question of severe thrombocytopenia in a patient with APS and an acute thrombotic stroke. I agree with his approach. However, this “between a rock and a hard place” clinical scenario does also appear not infrequently during the chronic management of patients with APS...
What is your approach to using apremilast for psoriatic arthritis in patients with history of depression?
Depression is a common comorbidity of psoriasis and psoriatic arthritis (20% at least mild and 14% at least moderate in a recent meta analysis). Depression is a known but relatively infrequent side effect of apremilast (<1.8% in clinical trials). It is important to screen for depression in all patie...
How do you approach NSAID use in patients on SSRIs?
This is a good question, the combined RR for NSAID+SSRI/GI complications is ~12. I generally avoid the combination and utilize topical NSAIDs if possible. I also discuss the possibility of switching patients from a 'traditional' SSRI to duloxetine, which is FDA approved for the treatment of primary ...
How do you approach management of patients with active RA and recurrent non-severe C.diff?
I think the question here is why the patient is experiencing recurrent C.diff. Is it true recurrence or it never fully clears? Any IgA deficiency? CVID? I would do an immune deficiency work up- complements, immunoglobulines and flowcytometry, response to pneumococcal vaccine. In parallel to the wo...