Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach the evaluation and management of a patient with rheumatoid arthritis receiving leflunomide who presents with progressive peripheral pulmonary cavitary nodules, with biopsy revealing necrotizing granulomatous inflammation?
Given the association between leflunomide and nodules with necrosis and giant cells (though quite rare), I would consider stopping leflunomide and moving to another agent. I would, of course, make sure that cultures are negative on those nodules, given it could be mycobacterial, fungal, or even GPA.
How do you counsel patients with osteoporosis and cervical spine osteoarthritis who are considering chiropractic cervical manipulation or traction?
I am concerned with the risks of actually causing a fracture or nerve impingement/damage. So, I would recommend against.
What is the role of the rheumatologist in recommending and providing GLP-1 medications to their patients given the benefits across many disease domains including osteoarthritis?
Obesity has long been discussed in the literature as the most modifiable risk factor for knee osteoarthritis pain and progression, with a reduction in knee OA attributed to the decrease in mechanical load. But for the last decade, there has been much attention placed on the impact of metabolic facto...
In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?
In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving...
When stopping denosumab and transitioning to PO bisphosphonate, do you wait for 6 months after the last denosumab injection to start PO bisphosphonate?
Some background: In patients discontinuing denosumab without subsequent antiresorptive therapy, BMD rapidly reverts back to baseline with an elevation in vertebral fracture risk (with an enhanced risk of multiple vertebral fractures). Thus, sequential treatment regimens following denosumab have been...
What monitoring would you pursue in a female patient with repeatedly very high titer centromere antibodies but no clinical symptoms of systemic sclerosis or other connective tissue disease?
For an asymptomatic patient with very high–titer anticentromere antibodies (ACA), monitoring should focus on early detection of systemic sclerosis (SSc) and related organ involvement, as higher ACA levels are associated with increased risk of progression. Risk stratification is informed by the devel...
How do you approach decision-making around initiation of osteoporosis therapy in patients with advanced dementia?
Great question, there are many things that I consider. First, I limit consideration of osteoporosis therapy to patients who have a life expectancy of 1 year or more. This is because the time to benefit from a bisphosphonate is estimated to be about 12 months (Deardorff et al., PMID 34807231). Assumi...
In what cases, if any, do you find the use of naltrexone to augment lifestyle interventions (i.e., cognitive behavioral therapy, graded exercise therapy) for chronic fatigue to be helpful?
Yes
Are there any successful disease modifying therapy for diffuse idiopathic skeletal hyperostosis (DISH)?
Therapy for DISH is largely supportive: PT, NSAIDs/pain relievers, and control of contributing metabolic conditions, nutrition, exercise, and lifestyle changes; when necessary surgical interventions such as surgical resection of osteophytes and spinal fusion are required.Clinical research in DISH is...
How would you approach diagnosis of a patient with recurrent episodes of abdominal pain, severe myalgias, low grade fevers and urticaria?
Without the mEFV variant, from a rheumatologist viewpoint, the differential includes IBD, a periodic fever syndrome such as FMF or FCAS, and MCAS. Therefore, I would consider that workup with genetic testing (anyone can send!), fecal calprotectin, and MCAS eval with A/I. I don't think of urticarial ...