Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach a patient with axial spondyloarthritis who develops new-onset proteinuria?
I would approach the workup for proteinuria based on the differential diagnosis with leading etiologies including, acute illness, diabetes, nephrotic syndrome (minimal change disease, FSGS, membranous neuropathy), drug-induced proteinuria, vasculitis, and of course IgA neuropathy. Standard studies i...
What would be your approach to a SLE patient who is triple APS positive, has no prior VTE/obstetric events, is stable on HCQ and low dose aspirin, and wants to become pregnant?
As long as lupus is well controlled, I would not recommend making any changes. I would also reassure this patient that having prior successful pregnancies (based on the information provided in the question stating that there were no prior obstetric complications) is a good sign. I would not prescrib...
Is it ever appropriate to restart bipshosphonates following a drug holiday in a patient with a prior atypical hip fracture?
I agree with Dr. @Dr. First Last. I am not likely to ever prescribe a bisphosphonate after someone has had an AFF (or ONJ) attributed to the bisphosphonate. Anabolics make sense if you can get them paid for. Raloxifene is fine but there is no evidence for non-vertebral fracture risk reduction. Venou...
How do you treat Raynaud's in patients with baseline low blood pressure?
These can be very challenging patients. I tend to try 2.5 mg amlodipine at night which they can often tolerate. If there is a component of anxiety or stress/emotion to the Raynaud's, particularly in primary Raynaud's, fluoxetine can be useful. Some patients can tolerate half-dose sildenafil (10mg TI...
Does the presence of facet joint effusions on lumbar spine MRI increase your suspicion for axial spondyloarthritis?
Isolated joint effusions in the lumbar spine are not indicators of AxSpA. Involvement in the spine in AxSpA involves more than the facet joint including adjacent entheses linking one vertebra to another and the costochondral joints. To arrive at this answer, I spoke to rheumatologists with expertise...
Are there concerns with using sulfasalazine in SLE?
A very practical question:1. Yes, there is a concern theoretically; but you can use SSZ in lupus patients in certain circumstances.Sulfonamides are divided up into antibiotic (abx) sulfonamides (like trimethoprim-sulfamethoxazole, TMP-SMX) and non-abx sulfonamides (e.g. furosemide, hydrochlorothiazi...
How often do you monitor labs in patients taking methotrexate?
Lab monitoring for patients taking MTX should be based on a few key principles. It should be done at least on a quarterly basis, ie every 3 months, if the patient is prescribed a stable dose and does not belong to one of the higher risk categories for the development of toxicities. These risk factor...
How would you treat inflammatory arthritis in a patient with Sjogren's syndrome and ILD (on mycophenolate) that is not responsive to hydroxychloroquine?
Fortunately, the Sjögren's Foundation has worked hard in providing us with evidence-based guidelines to answer these sorts of questions. I would go by the "Treatment Guidelines for Rheumatologic Manifestations of Sjögren's." The working group using the Delphi consensus process did all the hard work ...
How would you approach the work up of SLE in a patient over 80 years old?
Elderly onset lupus is uncommon and in the past twenty-five years has been reported to occur in as few as 6% of patients to as many as 19% of patients with the diagnosis of lupus. Typical clinical presentations tend to include arthritis/arthralgias, fever, weight loss, lymphadenopathy, serositis, si...
What is your treatment approach to persistent chillblains lesions in the absence of systemic lupus?
In idiopathic chillblains/perniosis, I think treatment centered on lifestyle modifications is key. As this is a cold-associated dermatosis, counseling patients to wear warm gloves or socks and avoiding cold exposure is important. Beyond lifestyle modifications, I typically start with a high-potency ...