Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach management of chronic cough in patients with ILD?
By the time an individual presents with ILD and cough, and fibrotic therapy has started, there’s almost no use for increasing the dose to treat cough instead of a neural modulator such as gabapentin, and if cough is interrupting sleep, low-dose narcotics. The spinoff is that narcotics may reduce dia...
How often are you repeating screening PFTs in patients with SARDs who have 3 or more years of normal or stable PFTs?
The answer to this question is complex and needs to be tailored to the individual patient’s risk for ILD and the particular SARD.Approximately 30-40% of patients with systemic sclerosis (SSc) will develop ILD, typically within the first 5 years after the first non-Raynaud’s manifestation and rarely ...
What cosmetic options can you provide to patients with facial discoid lupus that seems stable?
Procedures such as botulinum toxin A, fillers, and autologous fat grafting can be considered in patients with discoid lupus if the disease has been clinically stable, typically meaning no new lesions or active inflammation for about a year. Light-based vascular treatments such as pulsed dye laser ca...
Do you provide empiric doxycycline for Lyme Disease to asymptomatic patients after a tick bite who haven't developed Erythema migrans or are not sure it was an Ixodes tick?
I would base post-exposure prophylaxis upon local prevalence (unless the patient has a recent notable travel history). For example, Lyme disease is very rare in California due to the Ixodes tick's intermediate host being the Western Fence Lizard (long story short, something in their blood kills the ...
How do you weigh the risks of re-treatment with infliximab in a patient who has been off it for over a year?
To answer this question, we first need to go back in time. Treatment with infliximab has been known to elicit the formation of antibodies against infliximab. The presence of these antibodies has been associated with infusion reactions in 7-19 % of patients and may also shorten the duration of the ef...
What are the clinical prompts that lead you to consider deprescribing bisphosphonate therapy in older adults with osteoporosis?
As a Geriatrician, the essence of my practice is to determine, on regular review (reconciliation), whether an older adult’s medication is appropriate to continue or continue at the same dosing on the basis of physiology, pathology, and/or risk modification. We know well today that medications for os...
Are there specific conventional DMARDs and/or biologics that are contraindicated in patients with alpha-gal allergy?
Here is a Q&A from AAAAI (American Academy of Allergy, Asthma and Immunology) addressing this question for etanercept and other monoclonal antibodies that are manufactured in cell lines that glycosylate with alpha-gal. The author concludes, "The risk is not zero, but likely very low".
What are some practical tips for eliciting an accurate history of Raynaud's phenomenon in patients being assessed for CTD?
I use this approach. I first ask patients if they feel generally sensitive to the cold. All patients with Raynaud's should respond yes to this, but this is not specific, as there are many cold-sensitive patients who don't have Raynaud's. I will then ask if their fingers turn any colors in response t...
In patients with RA on methotrexate and a TNF inhibitor who develop PJP pneumonia, how long do you hold immunosuppression before restarting therapy?
I would typically hold immunosuppression until the patient has completed therapy unless they had significant respiratory failure, in which case I would await full recovery. The patient should be placed on appropriate PJP prophylaxis prior to resuming therapy.
How do you approach a child with recurrent parotitis who has had negative serum testing for Sjogren's and IgG4 related disease?
Minor salivary gland biopsy is pretty random and subjective; finding >50 lymphocytes per set field is not that specific/helpful. I would think a parotid gland biopsy and extensive work-up (TB, HIV, sarcoid, lymphoma, etc.) is in order.