Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When do you consider the use of JAK inhibitors for cutaneous manifestations of myositis?
JAK inhibitors have been shown to be effective especially for skin manifestations in dermatomyositis in an open-label trial (Paik et al., PMID 33258553). However, given the limitations imposed by insurance companies, I consider JAK inhibitors most commonly in the following scenarios: when the patien...
Would you escalate therapy in a patient with rheumatoid arthritis without synovitis, but a new rheumatoid nodule?
The appearance of a new nodule in someone without synovitis is puzzling. If it is truly a rheumatoid nodule, their RF should be positive. These patients have a heightened risk for the development of full blown RA in the future. However, the appearance of a nodule without synovitis being present does...
How do you approach the treatment of bullous cutaneous lupus?
First, I ensure that the diagnosis is correct (referring to my favorite local medical dermatologist) and that it is not a non-lupus-related bullous disease. As most would do, I use hydroxychloroquine plus dapsone as my initial treatment of choice along with strict ultraviolet light protection measur...
Would you modify your treatment approach for treating an HPV-positive head and neck cancer in a patient with symptomatic Sjogren's?
Patients with Sjögren’s syndrome have baseline xerostomia of variable severity. Management of Head and Neck cancer in this population depends on the location and stage of the primary. I would prefer to treat them with primary surgery if at all possible. If RT is necessary either as primary modality ...
When would you consider utilizing bone scintigraphy in the assessment of inflammatory arthritis?
When it's a case of negative RA disease or when considering a neoplastic, gammopathy with myeloma...
Do you typically adjust or hold immunosuppression in a well-controlled RA patient who is being treated for Mycobacterium avium-intracellulare (MAI)?
It depends on the RA activity and shared decision-making with the patient. A lot of these patients are at risk of MAI infection due to their underlying immunosuppression and on higher levels of immunosuppression because they have more severe rheumatoid disease process. Very often it is difficult for...
How would you approach a pulmonary-renal PR3+ ANCA vasculitis patient who has persistent re-narrowing of mainstem bronchus after several dilatation and stenting procedures, with other anca features well-controlled on rituximab & avacopan?
Obviously, this is going to be a very challenging management issue. Bronchial or tracheobronchial stenosis evolves independently of other organ involvement and often fails to respond to immune suppressive regimens. There is one anecdotal study from France, suggesting that cyclophosphamide may offer ...
Are there certain patients in whom you would avoid initiation of ULT during an acute gout flare?
Yes, I usually avoid it during first-time visits for gout flares. This is because the amount of information required during that visit would include: The acute gout flare management, and Information about gout in general. Commonly, this is in addition to other intercurrent medical problems. Addin...
How will you sequence therapies in dermatomyositis given the results of the ProDERM trial?
I will try oral immunosuppressants first, either methotrexate, azathioprine, or mycophenolate first; and then add IVIG if there is no response or even minimal response.
What is the approach to use of ACE inhibitors for suspected scleroderma renal crisis in patients with only mildly elevated BP and renal artery stenosis?
I recommend using a short-acting ACEi, like captopril, to treat scleroderma renal crisis. You can start at 6.25mg TID and rapidly titrate up the dose to achieve blood pressure goals. The presence of renal artery stenosis (RAS) would not dissuade me from using an ACEi, if there is evidence of thrombo...