Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach a patient with class III and V lupus nephritis, already on HCQ, MMF, voclosporin and losartan, but has continued proteinuria not yet attaining complete renal response?
Few things are more complicated than lupus nephritis, and this question is not answered easily. It depends on hematuria, Cr, proteinuria, C3, C4, dsDNA, and systemic symptoms. So, it depends on what I think is causing the incomplete clinical response. If I believe it is the class V lesion, I would g...
Do you routinely recommend delaying dental extractions in patients who have recently received intravenous bisphosphonate therapy for osteoporosis treatment?
I don't because the risk of osteonecrosis of the jaw (ONJ) is very low.
Would you start romosozumab in an active smoker?
This is not simple! But we are good at assessment of risk vs benefit (or benefit vs risk!)First I would reassess fracture risk, prior treatments, reason to consider romo. Then I would do a deep dive into risk assessment for cardiovascular disease: how much do they smoke, prior cardiovascular disease...
How would you treat a patient with osteoarthritis of just one joint of the hand?
People do this in various ways - some people treat the joint with a large margin, others may treat the whole hand.I originally started by treating the affected joint, but pretty soon I after I switched and started treating the whole hand - pain is subjective and though it may appear localized, there...
How do you clinically and diagnostically distinguish stiff skin syndrome from scleroderma?
One other disease consideration that one should differentiate is diabetic cheiroarthropathy, or "diabetic stiff hand syndrome." These patients can see decreased extension of the digits (often referred to as "Prayer sign" changes) and thickening of the skin in the digits. This can be present in 50% o...
In patients without Raynaud’s, how frequently do you perform nailfold examination during the initial clinical assessment?
Doing a simple bedside nailfold examination (inspection with the naked eye, otoscope/dermatoscope) is important to do at least once, as part of the general physical examination on all patients, irrespective of Raynaud’s. It might not add value or need to be repeated routinely in patients without Ray...
In a patient with biopsy proven statin associated immune-mediated necrotizing myopathy who previously responded well to methotrexate but now presents with recurrent proximal leg weakness and rising CK/aldolase levels after several years of stability, what would be your preferred next-line treatment strategy?
That's an excellent question. I would approach this as a probable disease flare, after excluding potential triggers such as statin re-exposure, including over-the-counter supplements (e.g., "natural" cholesterol-lowering mushroom products that may contain statin-like compounds). In that setting, I w...
In a patient with high +SSA antibodies and distal renal tubular acidosis (RTA), but without sicca symptoms or other systemic features of Sjogren's, should immunomodulatory therapy with hydroxychloroquine or azathioprine be considered in an effort to reduce subclinical tubular inflammation and prevent progression of renal disease?
Renal disease can occur as an initial manifestation in the absence of sicca in SjÓ§gren’s disease (SjD) patients (Goules et al., PMID 31464673). This is important to realize for other systemic manifestations of SjD (e.g., cystic lung disease, tubulointerstitial nephritis, radiographic nephrocalcino...
Would you pursue a kidney biopsy in a patient with stable stage 1 AKI, bland urine sediment, and a positive MPO titer without systemic signs of vasculitis?
PR3-ANCA and MPO-ANCA are associated with substantially higher specificities and positive predictive values for ANCA-associated vasculitis (AAV) than the immunofluorescence patterns to which they usually correspond (C-ANCA and P-ANCA, respectively). However, false-positive results remain a concern. ...
What is your approach to explaining the role of the microbiome to patients with inflammatory arthritis?
The gut microbiota play a central role in modulating the inflammatory response. This is especially relevant to inflammatory arthritis, where the pathogenesis is quite well understood, especially as it relates to arthritis associated with inflammatory bowel disease. We also know that the diet is the ...