Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In which osteoporosis patients would you consider starting with anabolic therapy over antiresorptive therapy?
Anabolic therapies including teriparatide (PTH-analog), abaloparatide (PTHrP-analog), and romosozumab (anti-sclerostin) are all indicated for patients with osteoporosis and high fracture risk. Although denosumab (anti-RANKL) is an antiresorptive agent, it also leads to significant bone gain similar ...
When treating patients with low bone mineral density, when/how do you monitor bone turnover markers (NTX, CTX, etc)?
It is a bit difficult to answer this question without more information. If you are monitoring a patient during a drug holiday, I would order a CTX-1 and PINP when discontinuing the bisphosphonate and then again after one year. If the levels have increased over 50% from the year before that would tri...
What is your treatment algorithm for RS3PE?
RS3PE is an interesting condition. In my experience, it typically presents older individuals aged 70 and beyond. Men are more commonly affected. The upper extremities are generally involved unilaterally or bilaterally. In cases of unilateral involvement, one should consider other diagnoses as well, ...
What is the role of nintedanib in the treatment of SSc-ILD?
Nintedanib has shown to be effective for treating patients with ILD associated with systemic sclerosis, as the annual rate of decline in FVC was lower with nintedanib than with placebo (SENSCIS trial). However, the majority of patients treated with nintedanib in this trial were also on MMF therapy. ...
Is there a role for ultrasound in assessing for "clinically silent" inflammatory arthritis prior to tapering DMARD therapy?
This is an excellent question. Data have been mixed with regards to the significance of sonographic synovitis (grayscale or Doppler) in "clinically silent" patients on immunosuppression. Initially, the question was asked in earlier papers whether such patients warrant an INCREASE in their immunosupp...
What agent would you choose for a patient who needs osteoporosis therapy after a bisphosphonate holiday?
This is a question of high clinical importance but with a lack of good controlled data. First and foremost, a holiday should be viewed as a temporary discontinuation of therapy. Anecdotally, I would say about 30% of my patients need to go back on therapy. There is a lack of data to support clinical ...
When suspecting a diagnosis of complex regional pain syndrome (or reflex sympathetic dystrophy), what workup should be done to confirm or exclude it?
Every evaluation begins with a thorough history and physical, particularly to look for other explanations of pain to this region. In my opinion, unilateral symptoms are much easier to assess than bilateral symptoms. Bilateral CRPS is reported but it is quite unusual. I am more likely to support a di...
In patients with knee osteoarthritis, do you recommend the use of hyaluronate injections if it is available and affordable for the patient?
This is a very controversial topic because the data simply hasn't been convincing. Many professional medical societies have either rejected HA or recommended it conditionally (or recommended against it conditionally). That being said, the literature has plenty of case series and reports of great rel...
How do you differentiate between axial psoriatic arthritis and axial spondylitis with psoriasis, and is it important to distinguish between these two conditions from a prognostic and treatment perspective?
This is an ongoing controversy in the field(s), with some studies suggesting that clinical differences allow differentiation of axial involvement in psoriatic arthritis from classical ankylosing spondylitis. The concept was recently the topic of a study by Feld and colleagues published in Rheumatolo...
Do you choose rituximab or calcineurin inhibitors for patients with class IV/V lupus nephritis who are refractory to standard of care therapies?
In severe active lupus nephritis, I use rituximab for refractory cases although tacrolimus is an option with published data for induction of lupus nephritis. There have been some instances where I have used both medications together. Things to keep in mind when making this decision include the prof...