Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you typically screen patients for antiphospholipid antibodies in autoimmune diseases besides lupus in the absence of a clotting event?
I would check antiphospholipid antibodies (APLAs) in a few situations in the absence of thrombotic events: 1. In someone with other APS manifestations: Obstetrical complications (especially) APL nephropathy noted on renal bx Unexplained adrenal hemorrhage/microthrombosis Non-infectious endocardial v...
How would you counsel a patient who is interested in using supplements (such as fish oil or turmeric) as an adjunct to treatment of inflammatory arthritis?
Drs. @Dr. First Last and @Dr. First Last expertly raise the key difficulty rheumatologists face with herbal medications: imparting a healthy respect for the potential risk:benefit (and limited data) about these agents against allowing patients to erroneously characterize their physician as close-min...
Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?
Great question, with practical implications for the clinic: Azathioprine (AZA) is a prodrug that likely exerts its immunosuppressive effects against B- and T-cell function by interfering with purine metabolism through its metabolites (including 6-MP). Logically, many of the "classic" AZA side effect...
How do you approach methotrexate management around vaccines other than COVID and influenza?
The COVID pandemic has highlighted impaired vaccine responses in our patient populations and current data was nicely summarized in Friedman et al., PMID: 34493491.Evidence had preceded the pandemic regarding diminished response to pneumococcal vaccination in patients with RA on methotrexate. My appr...
How do you approach treating idiopathic aortitis?
Before classifying a patient as ‘idiopathic’ or ‘clinically isolated aortitis’ (CIA), one must carefully consider that the aortitis may be a manifestation of a systemic condition, particularly giant cell arteritis or Takayasu arteritis. Other systemic diseases associated with aortitis include IgG4-...
How would you manage gout with hyperuricemia >10 mg/dl despite the maximum dose of allopurinol plus probenecid and a prior allergic reaction to pegloticase?
I am not sure what dose of allopurinol the patient is taking, how long he was on pegloticase, and if he had MTX or MMF with it. I can usually reduce the uric acid level with allopurinol and febuxostat. The key question here is whether the patient is taking the drug daily or not.
How do you time Evenity after completion of Forteo?
If a physician is considering transitioning an osteoporotic patient from a PTH treatment to romosozumab, there is no reason to delay. It should be fine to start romosozumab immediately upon discontinuing PTH if it is clinically indicated. However, it is important to remember that romosozumab has a b...
How do you approach selecting biologic therapy vs non-biologic DMARD (such as methotrexate) as initial therapy in patients with new RA diagnosis with significant erosive disease?
In my clinical experience, not everyone is the best candidate for methotrexate. Businessmen who feel alcohol consumption is part of their ability to finish business deals are uncomfortable taking methotrexate and I am uncomfortable prescribing for them. Men and women who are hoping to bear children ...
Is there utility in monitoring IgE levels in patients with IgG4-RD?
Serum IgE levels are associated with disease extent/severity and risk of relapse in patients with IgG4-RD. In some patients (although this is not true for all patients), IgE decreases following treatment and increases with disease flares. However, some patients who have extreme IgE elevations at bas...
How do you gain access to quinacrine, and what has your recent experience been?
It can be gotten from a few compounding pharmacies. The cost is high (around $400 a month) and usually not covered by insurance. One compounding pharmacy that often carries it is ChemistryRx in Philadelphia.