Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you feel comfortable combining mycophenolate mofetil with azathioprine in patients with lupus?
Aggressive immunosuppression is occasionally indicated for patients with lupus. Examples include refractory lupus nephritis, lupus with secondary CAPS, refractory immune-mediated cytopenia, etc. Treatment options often consist of high-dose steroids with at least one other immunosuppressive agent. Ad...
In a pediatric patient diagnosed with orbital sarcoidosis (dacryoadenitis) on biopsy, would you recommend completing evaluation for pulmonary sarcoidosis and neurosarcoidosis?
Presumably, the biopsy reveals non-caseating granulomas. Chronic dacryoadenitis can be seen in a variety of settings, including ANCA-associated vasculitis, Sjogren, IgG4-related disease, Crohn's disease, Lyme disease, tuberculosis, EBV, etc. Additional sarcoidosis workup will in part depend on other...
What is your approach to a patient who has a cardiac PET scan suggestive of sarcoid but no other supporting evidence of a diagnosis of sarcoid?
The diagnosis of cardiac sarcoidosis (CS) can be challenging, as non-necrotizing granulomatous inflammation is frequently patchy, and as a result, may not be present on endomyocardial biopsy even in the setting of active cardiac disease. Many institutions, including ours, attempt to avoid endomyocar...
Is febuxostat a safe alternative for patients who are HLA-B*58:01 positive and of Han Chinese descent?
Cutaneous reactions to allopurinol range from the mild to the very severe and life-threatening such as Stevens-Johnson's Syndrome (SJS) and toxic epidermal necrolysis. The association of these reactions is so strong as to have its own acronym, AHS, for the allopurinol hypersensitivity syndrome.These...
Do you generally recommend low dose aspirin for patients with giant cell arteritis?
I generally do not use aspirin routinely in patients with GCA. While several retrospective series suggested a benefit to ASA for preventing ischemic complications in GCA (e.g. Nesher et al., PMID 15077317), this data is limited by its retrospective nature, small numbers, and significant confounding....
What is your approach to management of chronic recurrent parotitis in patients with Sjogren's Syndrome?
Uncommon, however, I consider chronic infection/reinfection, especially in setting of significant immunocompromise or severe dental/periodontal disease. Secretion from stensen duct os can be cultured.Salivary duct stones can be detected by ultrasound if ~ >2mm, and duct dilation seen.Especially if c...
What is your approach to a patient on long-term denosumab who now requires multiple invasive dental procedures?
This is an important issue and one our practice faces routinely. We have close to 2,000 patients on Prolia. When we initiate Prolia we discuss the concern about rapid bone loss associated with discontinuation. We advise that if they need a dental extraction we hope they can get it done before initia...
How do you manage diarrhea in a patient with CTD-ILD on MMF who was recently started on full dose nintedanib?
It is important to keep in mind that immunomodulator therapy is also frequently associated with gi toxicity (MMF, methotrexate, leflunomide, azathioprine, etc.). Given this, it is important to begin one therapy at a time in order to mitigate side effects and do understand which agent is responsible....
Do you delay spinal surgery (e.g. lumbar decompression for stenosis) in men or women with newly diagnosed osteoporosis and multiple thoracic compression fractures (not involving site of potential surgery) in order to initiate anabolic or anti-resorptive therapy to potentially improve surgical healing outcomes?
This is a fairly common clinical issue. Increasingly, spine surgeons are requesting anabolic bone medications prior to the type of surgery outlined in the question. Our approach has been to use three months of such treatment prior to the surgical procedure and then to continue that treatment after t...
Do you hold rituximab for cataract surgery?
I never stop any immunosuppressants for cataract surgery. The reason being, it may help prevent postoperative ocular eye inflammation (e.g. postoperative iritis). I learned this many years ago when one of my RA patients stopped their methotrexate and had a severe bout of new-onset iritis afterward. ...