Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you dose steroids in neurosarcoidosis patients with a worsening clinical symptoms or MRI findings?
The route of dosing of glucocorticoids for neurosarcoidosis typically depends on the severity of illness and symptoms. For example, significant CNS involvement on imaging or patients presenting with AMS, weakness, vision changes/loss, or seizures would benefit from IV methylprednisolone followed by ...
How do you manage patients on biologics peri-operatively?
There was an article in the NEJM Journal Watch in regards to stopping biologics (DMARDs and TNFs) for rheum disease before surgery, and there was no statistically significant benefit in regards to surgical recovery but, as expected, flares of the Rheum disease. In regards to the newer targeted injec...
How do you approach the use of parathyroid hormone-related protein analog drugs in the setting of prior external beam radiation?
The concerns about prior external beam radiation are due to the independent increased risk of osteosarcoma associated with external beam radiation. The boxed warning associated with the PTH anabolic drugs WARNS that patients with prior radiation should not receive PTH anabolic drugs. (Note this is n...
Would you consider PTH-analog therapy in a woman with osteoporotic vertebral fractures who has asymptomatic non-obstructive renal stones and normal 24-hour urine calcium level?
With the limited information posted, my answer would be yes. I would likely choose abaloparatide as it seems to have less of an issue with hypercalciuria than teriparatide. Another option for an “anabolic" drug would be Romosozumab which would not be a drug about which hypercalciuria is a concern.
Is there a subset of ANCA vasculitis patients for which you would try plasma exchange?
Circling back to this now that we have more data. I agree with Dr. @Dr. First Last's main conclusion that GN or the presence of concomitant anti-GBM antibodies are the primary scenarios in which there may be a role for plasma exchange patients with ANCA-associated vasculitis.Following the PEXIVAS tr...
What is your approach to ongoing assessment and medication tapering in well controlled discoid lupus without systemic features?
As with many systemic lupus (SLE) complications, the patient with discoid lupus (DLE) is often best managed by a rheumatologist in tandem with a specialist of that complication, in this case, a good medical dermatologist experienced with cutaneous lupus. Although I think I am good at telling most ac...
How do you approach monitoring when using combination JAK inhibitors and methotrexate in RA?
It is important to return to the package insert and/or the original clinical trials for these medications when considering options for care and use. Tofacitinib, for example, when tested for the management of rheumatoid arthritis, was in phase 2 and 3 studies in combination with DMARDs, including me...
What is your approach to progressive calvarial hyperostosis found in an elderly adult not caused by Pagets, acromegaly or hypercalcemia?
Does your patient have meningioma? Is the osteosclerosis generalized or localized? Localized osteosclerosis can arise from tumors (either benign or malignant) that secrete osteogenic proteins. I have had such a patient, with the unresectable meningioma secreting endothelin. Endothelin is also secret...
What is your management approach for patients with Adult Onset Still's who are planning pregnancy?
Adult Onset Still's Disease is an uncommon disorder. There are a paucity of studies of this disease during pregnancy. Nonetheless, as rheumatologists, we are occasionally asked to manage these patients during pregnancy. The treatment of Adult Onset Still's Disease includes NSAIDs, glucocorticoids, m...
At what point in GCA management do you typically introduce tocilizumab?
I typically introduce tocilizumab as first line therapy in combination with prednisone in patients who do not have a contraindication. The GIACTA trial demonstrated the superiority of TCZ+prednisone x 6 mos over prednisone alone x 6 or 12 months with numerically fewer serious adverse events. Given t...