Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to treating premenopausal woman with OI with a new compression fracture?
Young women with idiopathic premenopausal osteoporosis likely have low bone formation. I was not told her BMD but I will assume it is low. An antiresorptive does not make much sense because she is producing enough estrogen to keep her cycles going. There has been some published data with the use o...
Is there practical utility from obtaining CSF autoantibodies in patients with suspected neuropsychiatric systemic lupus erythematosus?
I typically obtain serum and CSF autoimmune encephalopathy panels based on a patient's APE2 score. A score of 4 or more is predictive of having positive serum or CSF antibodies and can be applied to patients with neuropsychiatric lupus and help stratify who to test. I would start the workup with MRI...
How do you decide when to try stopping hydroxychloroquine in patients with erosive osteoarthritis?
As we lack any peer-reviewed evidence that hydroxychloroquine (HCQ) effectively and significantly helps with erosive osteoarthritis, I would stop the drug if there was no relief within 2 months (if I had started it for a patient). While HCQ (and other DMARDs) are often used empirically with these er...
How do you approach treatment of PMR in a patient who has had avascular necrosis of the hip after starting steroids?
In this clinical scenario, I strongly advise avoidance of steroids. The data looks promising for using anti-IL-6 therapy in PMR. I don’t think it should be considered first-line therapy for our patients yet but should be reserved for those who have major contraindications or issues regarding the use...
How would you manage warfarin in a patient with APLS and alcoholic cirrhosis?
This is an interesting and challenging question that would require a case-by-case review by a team of rheumatologists, hematologists, and hepatologists, as well as an in-depth discussion of the potential risks and benefits with the patient. This reference, O'Leary et al., PMID 30986390, provides a g...
For a patient with osteopenia or osteoporosis, how long can intravenous zoledronic acid be maintained if there are not adverse events?
I generally prescribe Zoledronate annually for three years for patients with osteoporosis who are at increased fracture risk. I will occasionally add an additional treatment 18-24 months after the third infusion if there has been a positive response to the original treatment regimen and I feel that ...
Do you use MTX along with Rituximab in patients with early NSIP on HRCT in patient with active RA and polymyositis (PL7+)?
The reluctance of using methotrexate in ILD is mainly due to the risk of pneumonitis. So, I would use MTX in a patient with ILD if their pulmonary reserve is adequate to withstand a case of pneumonitis, which is a rare event. Otherwise, I would azathioprine or tacrolimus in combination with rituxima...
Is polymyalgia rheumatica associated with increased toxicity for lung SBRT?
No data here that I can speak to. Lung involvement is exceedingly rare in PMR and generally, I wouldn’t consider this a disease associated with increased risk of inflammatory response within the lung parenchyma. There are some reports of associated GCA, BOOP, and other interstitial lung findings in ...
In a patient with history of scleroderma renal crisis resulting in ESRD, would you recommend using steroids for when needed?
The frequency and timing of recurrent Scleroderma Renal Crisis are largely unknown. Majority of the reports available are from patients with ESRD that underwent renal transplant with recurrence in allograft - overall this is rare, with most occurring between 3 months to 2 years post-transplant, but ...
How would you treat a patient with necrotizing myopathy with positive anti-HMHCoR Ab unresponsive to standard therapies?
There are several questions raised by this scenario. I have personally never seen a patient with true HMGCR-antibody + necrotizing autoimmune myopathy fail a combination of 3 immunotherapies (high dose prednisone, IVIG, and either Rituximab or oral immunosuppression like Cellcept/azathioprine, etc),...