Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you counsel patients on the risks and benefits of strontium supplements for osteoporosis management?
No experts whom I know prescribe Strontium for osteoporosis. It has not been shown to be efficacious to reduce fractures, although bone density will rise substantially. Also, bear in mind of very serious toxicities that have been associated with this drug. I would never use it in any of my patients....
What is the role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
What recommendations do you provide patients regarding immunization or boosters prior to initiating rituximab?
To my knowledge, there is no unified recommendation, although the majority of us recommend all age-appropriate immunizations plus strong consideration of younger-than-standard-age immunization for diseases such as pneumococcus and VZV prior to initiation of rituximab when medically feasible. Timing ...
For patients with definite UIP and MPO-ANCA-associated vasculitis limited to the lungs (without systemic manifestations), what is the role of immunosuppression?
I think in these subjects (as opposed to UIP in RA), immune suppression would be my first agent. The data are limited; there is some suggestion on biopsy that they have significant inflammation (Arnold et al., PMID 38574743). I would start with immunosuppression and have a low threshold to add anti-...
What is your approach to treatment of macrolide-sensitive localized bone/joint MAC disease?
Agree with the above answers. Obviously, no strong clinical studies on duration and outcomes. At NJH, we typically recommend: Aggressive debridement/resection, Treat with appropriate antimicrobial therapy (in macrolide-S MAC, then AZM/EMB/Rifamycin +/- IV AMK) for a minimum of 6 months total, but a...
What is the role of skin biopsy for evaluating small fiber neuropathy in patients with rheumatic disease who have treatment recalcitrant pain?
I have a shared decision-making discussion with the patient, especially alluding to the fact that the result would not change my therapy (i.e., use neuropathic analgesics for treatment) for small fiber neuropathy (SFN). Where I find it especially useful is in a patient with systemic lupus (SLE) or S...
How often do you recommend ophthalmologic screening exams for patients with sarcoidosis?
The American Academy of Ophthalmology has guidelines for routine eye exams for an asymptomatic, healthy individual (not someone with sarcoidosis). These guidelines include a complete, dilated eye exam at age 40, interim exams at the discretion of the patient and one's ophthalmologist, and an exam ev...
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
What is your approach to the management of shrinking lung syndrome in SLE?
No consensus exists on the best way to diagnose shrinking lung syndrome (SLS). Interestingly, I rarely see this anymore. Possibly due to better treatments and universal use of hydroxychloroquine (HCQ)? We are not even sure how and why it occurs. Could it be a myopathy of the diaphragms or a result o...
What is your approach to using pegloticase in patients with congestive heart failure?
Clinical trial data show developing CHF exacerbation in 2% of patients while on Pegloticase treatment, while real-world data show higher numbers (6.4%), so careful patient selection and stabilization of CHF are necessary before starting treatment, and need close monitoring while receiving treatment....