Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach the evaluation of patients referred for chronic lyme disease and counsel patients regarding this entity?
"Chronic Lyme disease" is a term that needs careful definition before one can accurately evaluate and treat a patient. Is this chronic symptomatology with physical findings in a patient who actually had documented infection with B. burgdorferi in the past? Or are there no objective findings, no phys...
How would you approach management of a patient with a medium-to-large vessel vasculitis who developed perforation of the stomach and colon on steroids and cyclophosphamide?
The answer to this question is complex as will depend on the most likely option for the etiology of the perforation and the nature of the underlying vasculitis. If the perforation is felt to be because of vasculitic activity then the decision could be whether to continue the current therapy (not eno...
Should JAK inhibitors and anti-IL6 medications be avoided in patients with known diverticulosis?
The development of diverticulitis, including complications such as bowel perforation, has been reported in patients taking JAK and IL-6 inhibitors (for example, see here and here). As a result, a history of diverticulitis is a relative contraindication for these agents (and carry a “use with caution...
How do you manage patients with SLE undergoing assisted reproductive therapy with estrogenic effects?
For patients undergoing any form of assisted reproductive technology (ART), it is important to assess their SLE disease activity. If a patient has moderate to severe SLE disease, I recommend delaying ART until we have better control of their disease. Once we plan to move forward with ART, I check an...
Do you continue methotrexate in patients with inflammatory arthritis who develop non-melanomatous skin cancer while on therapy?
Data on methotrexate use and the increased risk of non-melanomatous skin cancers has been conflicting, suggesting an increased risk or a neutral risk. A recent case-control study published in the British Journal of Cancer (Polesie et al., PMID 36739322) did suggest an increased risk of both squamous...
Do you utilize serial MRI imaging in patients with axial spondyloarthritis to ensure good disease control or do you rely on symptoms and physical exam to assess treatment response?
The ACR 2019 guidelines recommend that MRI could provide useful information in cases where the level of disease activity was unclear and where this information would influence treatment decisions. For patients with nr-axSpA, the imaging should focus on the sacroiliac joints. In interpreting MRI resu...
Does the presence of a connective tissue disorder such as lupus or scleroderma modify your radiation dose or technique for prostate cancer?
Here another article that may be of interest. It's actually a hometown favorite at VCU since the lead author is on our faculty. J Clin Oncol. 1997 Jul;15(7):2728-35.Irradiation in the setting of collagen vascular disease: acute and late complications. Morris MM1, Powell SN. PURPOSE: Based on repor...
Are there patients with gout in whom you would choose febuxostat first line over allopurinol for urate lowering therapy?
While both allopurinol and febuxostat have shown efficacy in reducing uric acid levels, in most cases allopurinol remains the first-line choice with and is considered safe. The main exception is for patients of Asian descent (especially Chinese, Korean or Thai) or who are Black, as they have a much ...
What is your approach to patients with severe sicca symptoms and history of B Cell lymphoma?
For your patient with SjD, B-cell lymphoma, and severe sicca; in addition to treating them with HCQ, I would also: Be diligent with treating the sicca sxs proactively to prevent dental loss and vision problems using the previous guidelines (Zero et al., PMID 26762707 and Foulks et al., PMID 25881996...
How do you interpret negative HMGCR antibody test results in a patient with necrotizing myopathy who has already been on treatment with steroids and whose CK has normalized?
HMGCR antibodies tend to remain present over time, even during periods of disease remission. Only recently have we began observing negative results in patients undergoing long-term treatment. Therefore, considering the patient received steroids for only a brief period, it's reasonable to suspect tha...