Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend patients continue folic acid for a few weeks after methotrexate discontinuation?
If Methotrexate (MTX) is being discontinued due to a side effect or toxicity, it make senses to maintain the folic acid supplementation for an additional few weeks as this may help minimize some of the unwanted symptoms such as mouth sores or nausea. If MTX is being discontinued due to lack of effic...
Do you utilize post-vaccination IgG titers to detect common variable immunodeficiency in patients who are about to start or are actively on B cell depleting therapy?
I have checked M-M-R, Td, and pneumococcal titers in patients with hx of infection and low Ig levels to see if they are making an immunological response. If any of these immune titers are low or the immunization is “due” by routine schedules, I recommend immunization and repeat testing in 6 weeks. T...
What is your approach to patients with positive anti-CCP, negative RF and tobacco use, but no current signs of active rheumatoid arthritis?
There is considerable evidence supporting a link between citrullination of proteins including the generation of CCP antibodies and smoking. A number of studies that have followed patients with this clinical phenotype have identified a heightened risk for the development of full-blown rheumatoid arth...
Do you ever taper or stop urate lowering therapy in patients who have had no gout flares and serum urate persistently below 6 mg/dl?
Part 1: Yes, but not often.Part 2: No, or extremely rarely. Read on. Urate lowering therapy (ULT) mobilizes monosodium urate (MSU) deposits and in time will resolve all of the clinical features of gout. The formation of these deposits results from sustained serum uric acid (SUA) elevations in excess...
Do you recommend chlorhexidine mouth rinse for prophylaxis against oral complications in patients undergoing dental work who are immunosuppressed?
I have not, but would defer to dental/oral medicine colleague involved in patient care.Specifically in Sjogren's, I do not recommend chlorhexidine (CH). CH (antimicrobial) is indicated for gingivitis and periodontitis. Many of the formulations contain alcohol and dye, which are irritating for dry mo...
How do you differentiate the normal feeding vessel to the lunate from an erosion or power doppler signal on ultrasound?
Distinguishing erosion from lacuna for feeding vessels on the dorsum of the lunate can be challenging, and most people have a lacuna in this location (Falkowski et al., PMID 32007818). True erosions are more likely to be greater than 2mm in width and irregular, while vascular channels are typically ...
Is there utility of modifying DMARD treatment in a seropositive rheumatoid arthritis patient with recurrent pleural effusions and RA nodules without other signs of active disease?
Modifying DMARD treatment in a seropositive RA patient without active articular disease may be useful when the patient has symptomatic noninfectious recurrent pleural effusions that are exudative requiring repetitive thoracentesis, frequent courses of systemic or intrapleural corticosteroids. Rheuma...
Does phosphatidylserine antibody play a role in the diagnosis of antiphospholipid antibody syndrome?
While additional APLAs such as aPS/PT are being investigated for clinical relevance, to date, they are not established markers for disease. I would interpret the aforementioned paper with caution, as these antibodies were tested in individuals with known and diagnosed APS. Their role in establishing...
At what point, if at all, do you decrease the frequency of or discontinue pegloticase infusions after achieving persistently low serum urate levels?
This is one of the most frequent questions physicians have about pegloticase therapy. To review, the goal of pegloticase therapy is to manage the gout patient who has an overwhelming disease burden from deposits of MSU in joints, bone and soft tissues. Frequent flares, chronic synovitis, tophi inter...
When is a kidney biopsy warranted in a patient with possible scleroderma renal crisis?
Scleroderma renal crisis (SRC) is a relatively early complication of Systemic sclerosis that almost invariably occurs within the first five years after the onset of the disease and may even be the initial manifestation of SSc. Abrupt onset of moderate to marked hypertension and acute kidney injury w...