Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you use hydroxychloroquine for prevention of neonatal lupus in patients with a positive SSA who are planning on becoming pregnant?
There is some evidence that hydroxychloroquine can prevent CHB in patients at high risk (mothers who already had a fetus with CHB in a previous pregnancy (Izmirly et al., PMID 32674792). There is scant evidence about neonatal lupus and the use of HCQ to prevent it. HCQ is generally well-tolerated an...
Is chronic major salivary gland enlargement in a patient with Sjogren's an indication for immune-modulating therapy such as hydroxychloroquine or methotrexate?
Although there have been 2 patients reported to have an improvement in parotid size with hydroxychloroquine and methotrexate are generally ineffective for the treatment of chronic bilateral major salivary gland enlargement in Sjogren's. For acute bilateral swelling, a tapering dose of prednisone can...
How do you treat small fiber neuropathy associated with rheumatic conditions like Sjogren’s syndrome?
Have primarily followed the recommendations of Julius Birnbaum's group from Hopkins Sjogren's Center and use neuroleptics, primarily gabapentin. The main issue for Sjogren's patients with significant sicca symptoms is that many of the options we have for neuropathic pain increase dryness symptoms, s...
How do you counsel patients who ask you about trying oral or topical formulations of medical marijuana for pain related to arthritis or fibromyalgia?
Despite the acknowledged widespread use of cannabis in rheumatology patients, there has been no evidence of its efficacy. A recent systematic review of randomized controlled trials found no evidence for the use of cannabinoids, cannabis, and cannabis-based medications in chronic pain management (Fis...
What baseline work-up do you do for patients with suspected palindromic rheumatism?
I'm sure this varies a lot by rheumatologists. For someone with a pattern of recurrent and episodic arthritis that sounds inflammatory, I think the differential diagnosis should include rheumatoid arthritis, gout, and calcium pyrophosphate deposition disease, polymyalgia rheumatica, and perhaps some...
Are there any clinical situations in which checking for anti-chromatin antibodies is helpful?
Chromatin is the native complex of histones and DNA found in the cell nucleus of eukaryotes. The prevalence of anti-chromatin (nucleosome) antibodies in systemic lupus erythematosus (SLE) varies from 50% to 90%, being similar to that of the historic LE cell.The question is whether this provides addi...
How do you manage severe Raynaud's phenomenon with ulceration in scleroderma patients that is refractory to oral agents (CCBs, PDEis, ARBs, and ERAs)?
Difficult question. First, I would make sure that the ulcers you are trying to treat are really ischemic in etiology. These would typically be ulcers that are on the fingertips in association with significant Raynaud's. Other etiology for ulcers would be trauma/skin fragility (over PIP joints most c...
How do you manage severe vaginal dryness and vulvodynia refractory to topical lubricants in patients with Sjogren's syndrome?
Exclude candida, vestibular gland blockage, and lichen sclerosis.First-line treatment option is vaginal estrogens (cream, ring) or low-dose systemic estrogen (tablet, patch).Second-line options include vaginal DHEA or vaginal testosterone.The severe vaginal dryness in Sjogren's is associated with ly...
Are there any features that help differentiate Sjogren's-related CNS demyelinating plaques from multiple sclerosis in a patient with primary Sjogren's syndrome?
This differentiation can be very difficult but the modified Barkhof's MRI criteria, perivenular lesions, and T2 lesions larger than 6 mm can be helpful in this regard. Helpful references:Kim et al., PMID 23736535Maggi et al., PMID 29328521
Is there a role for tocilizumab in treatment of polymyalgia rheumatica in patients who do not have features of giant cell arteritis or rheumatoid arthritis?
In select PMR patients with multiple relapses as corticosteroids are tapered or who have significant steroid toxicity, additional "steroid-sparing" agents may be considered. I do think in this setting tocilizumab may be useful. IL-6 has long been appreciated as a pivotal cytokine in PMR. Two studies...