Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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....
For patients who do not have access to biologic therapies, what are some csDMARD combination pearls or tips that you have that have particular efficacy in different rheumatologic diseases?
I normally use MTX in RA. I initially aim for 15mg of MTX per week, then split the dose and maximize to 20-25mg/week. In some patients, I use SQ MTX if they have GI problems or are very obese. The addition of HCQ with MTX is better than MTX alone in some patients. I have rarely used SSZ+MTX+HCQ but ...
How do you approach the decision to initiate or continue bisphosphonate therapy in an older patient with significant esophageal disease or swallowing dysfunction?
Unless there are indications to turn first to non-bisphosphonate therapies, I would first consider whether the patient would be a candidate for IV bisphosphonate therapy. Many patients, even those without esophageal disease or dysphagia, find the convenience of an annual outpatient infusion appealin...
In patients treated with infliximab, do rates of immunogenicity vary based on underlying disease (RA, IBD, sarcoidosis, etc) and/or baseline disease activity?
Yes, rates of infliximab immunogenicity appear to vary based on underlying disease, with evidence showing higher rates for RA than IBD and spondyloarthritis, and tend to increase with higher baseline disease activity. Most patients tend to develop anti-drug antibodies within the first year, but this...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
What were your top takeaways in Myositis from ACR Convergence 2025?
ACR Convergence had an outstanding selection of myositis offerings, and the number of people attending the sessions reflects the increasing recognition of these heterogeneous diseases, coupled with the frequency that non-myositis specialist clinicians will encounter these entities. The convention pr...
For what sort of SLE clinical profile do you favor anifrolumab beyond patients with prominent skin manifestations?
Skin disease is obviously the primary clinical manifestation. I will also prescribe it to patients with arthritis, pericarditis, mucosal disease, and hair loss. I await the results of the trial in lupus nephritis. I have an n of 1 experience with a patient with long-term high anti-dsDNA and low comp...
In a patient with recurrent episodes of GCA that flare shortly after steroid tapering, how do you differentiate between steroid-dependent inflammatory relapse, an alternative autoimmune vasculitic process, and a paraneoplastic phenomenon?
This could certainly be worrisome for a paraneoplastic phenomenon. GCA is associated disproportionately with myeloid lineage mutations (CHIP - clonal hematopoiesis of indeterminate significance). TET2 is think is the best-studied mutation, but in my experience, any other CHIP mutations such as ASXL1...
For patients <65 with significant intermittent steroid exposure who otherwise do not have risk factors for osteoporosis, when, if ever, do you recommend considering DEXA screening?
The FRAX guidelines recommend answering "Yes" for glucocorticoid use when a patient has received the equivalent of prednisone ≥5 mg daily for more than 3 months. However, many patients with rheumatoid arthritis have been treated with intermittent courses of corticosteroids over several years, which ...
How do you ensure that fibromyalgia is appropriately recognized in patients with Sjogrens?
I like Dr. Pisetsky et al's recent recommendation of naming this "nociplastic pain" rather than fibromyalgia. They were specifically talking about "lupus-associated nociplastic pain", but after reading their article, it should also apply to Sjogren's disease.I'd encourage everyone to read their very...