Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach folate supplementation for methotrexate-related side effects?
All MTX users should be taking some form of folate supplement. Either daily folic acid or weekly folinic acid are used and generally are effective. Tracking the RBC MCV is one way to ensure that patients are receiving adequate folate supplementation.The question has been raised whether folate supple...
How would you approach using the new vagus nerve stimulator for patients with RA?
Vagus nerve stimulation (VNS) may be a consideration for treating those patients with RA who have disease that is either resistant to multiple DMARDs and biological therapies, or where the risk of immune suppression significantly outweighs the potential benefits of our standard approach to managing ...
How do you use hydroxychloroquine in patients with lupus nephritis on hemodialysis or peritoneal dialysis?
After starting dialysis, other lupus manifestations frequently become clinically inactive. However, there is still a subset of patients who have clinical or serologic activity. Prior studies have shown that < 6% of lupus patients remain clinically active 5 years after starting dialysis, < 25% remain...
What Barrett's Esophagus screening protocol do you follow for patients with scleroderma given the increased risk of reflux and esophageal stasis?
This is an excellent question and is probably also relevant to mixed connective tissue disorder (MCTD) and overlap syndromes. My answer is a poor one - to my knowledge, we just do not have the data to guide us. I would certainly be more vigilant, but do not have a set protocol other than that for BE...
How do you approach immunosuppression in patients with rheumatoid arthritis and newly diagnosed bladder cancer who willl be starting intravesical BCG therapy?
I agree with Dr. Cappelli but there is an additional layer to the question. The concern is not just with efficacy of BCG treatment for bladder carcinoma when on these medications. There is the concern than anti-TNF therapy may increase the risk of dissemination of BCG, analogous to the experience wi...
Do you recommend avoidance of occupational/environmental exposures in patients with pulmonary sarcoidosis?
The best assessment of occupational exposures associated with pulmonary sarcoidosis comes from A Case Controlled Etiologic Study of Sarcoidosis (ACESS). This is nicely summarized in a state-of-the-art article that lists occupations and exposures with both positive and negative associations between o...
How would you define failure of anabolic therapy for severe osteoporosis and when would you consider ordering a second round of Evenity or PTH analogue therapy?
“Failure” of any therapy is often in the eyes of the beholder. The most efficient way to determine if there is anabolic activity is to measure a serum PINP (does not need fasting) and, for the PTH anabolic recheck, the PINP 2-3 months later. IF the delta is >10, you can be confident there is more pr...
How often do you see bony erosions in patients with Lyme arthritis?
There are three ways that Lyme disease can result in joint involvement. The most common is diffuse arthralgias (not a true arthritis) associated with the acute infection. This is self-limited and does not harm the joint. The second is an inflammatory arthritis that is similar to other infected joint...
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...
Would you start hydroxychloroquine (or another DMARD) in a mid-20s female patient with positive ANA, SSA, SSB, and dsDNA, whose only clinical manifestation is intermittent parotid gland swelling?
Hmm... I think the better question to ask is, do you code as Sjogren's lupus overlap to get way more medication options? Certainly, HCQ is a reasonable DMARD and a place to start for both diseases. I would code as lupus and Sjogren's to have more options for the future. Hope someone can weigh in on ...