Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to the diagnostic workup of small fiber neuropathy in patients with known rheumatic disease?
Small fiber sensory neuropathy (SFN), in general, including in patients with rheumatic diseases, should be suspected based on symptoms (positive more than negative sensory symptoms) and ideally confirmed by clinical examination showing altered temperature and/or pain/pinprick perception in the limbs...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
How do you envision incorporating CAR-T therapy into your clinical rheumatology practice?
This is an excellent question—one that, for now, might best be explored over a glass of white wine and some lively hand-waving. It’s a question I often find myself reflecting on every time I hear a presentation or read a new paper on the subject. Here’s a brief editorial response outlining how I env...
How would you manage resuming successful abatacept therapy in a refractory RA patient undergoing resection of stage 1 lung adenocarcinoma?
You can restart the abatacept once the patient has recovered from surgery. There is no signal for increased new solid tumors on abatacept, and you would expect the patient to be cured after resection of a stage 1 tumor.
How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?
As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD...
How do you manage severe Raynaud's phenomenon with ulceration in scleroderma patients that is refractory to oral agents (CCBs, PDEis, ARBs, and ERAs)?
Difficult question. First, I would make sure that the ulcers you are trying to treat are really ischemic in etiology. These would typically be ulcers that are on the fingertips in association with significant Raynaud's. Other etiology for ulcers would be trauma/skin fragility (over PIP joints most c...
In postmenopausal osteoporosis, would you switch to romosozumab (rather than a PTH/PTHrP analog) if a patient fractures while on denosumab?
This is an interesting question because it raises the subject of how one defines "treatment failure" among patients who are using bone-strengthening medications. I remind patients that our drugs are most effective at preventing spinal fractures with efficacy that can exceed 70% relative risk reducti...
In patients with connective tissue disease-associated interstitial lung disease (CTD-ILD) who have achieved clinical and physiologic stability after successful discontinuation of prednisone while on mycophenolate mofetil, how do you typically approach tapering or discontinuing the mycophenolate?
Unfortunately, there are no high-quality, evidence-based guidelines that specifically address tapering or discontinuing mycophenolate mofetil (MMF) in CTD-ILD after achieving clinical stability. The available literature strongly favors prolonged maintenance therapy rather than early discontinuation,...
How do you determine whether to add abatacept or rituximab to the treatment regimen in patients with mild RA-ILD on methotrexate?
I think of many agents before rituxan for RA ILD: all in various stages of being studied MMF, Orencia/abatacept, Tocli/actemra, and even JAK inhibitors xeljanz/rinvoq. Generally, if I treat and control the joints, the lungs stabilize. 10-20% run independently from joints or extra-articular ILD witho...
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...