Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to management of a patient with sarcoidosis who is asymptomatic, but demonstrates progressively enlarging mediastinal lymphadenopathy and rising soluble IL-2 receptor levels?
There are no diagnostic or prognostic biomarkers specific for sarcoidosis, and proposed surrogate markers for tracking disease activity, including soluble IL-2, serum angiotensin-converting enzyme (ACE), and even the presence of fluorodeoxyglucose (FDG)-avid lesions, have limited predictive value. F...
Do you regularly recommend an immunological workup for patients with suspected immunodeficiency or defer to immunology?
I defer after a very preliminary work-up based on the type of immunodeficiency expected. I try to direct the consult to a provider most likely to have expertise in the problem I suspect. Often, I suggest consulting with a provider at NIH.
What patient factors are most important when considering who needs a broader workup for osteoporosis prior to starting therapy?
A workup to rule out secondary causes must be done prior to starting therapy for osteoporosis. A good history and exam are recommended to look for any clues for modifiable factors. At a minimum, one should do CMP, 25-OH vitamin D, TSH, and a 24-hour urinary calcium or calcium/creatinine ratio should...
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...
How do you counsel patients with osteoporosis and cervical spine osteoarthritis who are considering chiropractic cervical manipulation or traction?
I am concerned with the risks of actually causing a fracture or nerve impingement/damage. So, I would recommend against.
In patients with ILD who are started on nerandomilast on top of background nintedanib, what monitoring is most important early in therapy?
While it may seem initially that combining antifibrotics is a bad idea due to side effect profiles, it has, in fact, been done with some success. The INJOURNEY trial combined nintedanib AND perfenidone in patients with IPF, and during the study period (12 weeks), those on combined therapy lost only ...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
How do you approach decision-making around initiation of osteoporosis therapy in patients with advanced dementia?
Great question, there are many things that I consider. First, I limit consideration of osteoporosis therapy to patients who have a life expectancy of 1 year or more. This is because the time to benefit from a bisphosphonate is estimated to be about 12 months (Deardorff et al., PMID 34807231). Assumi...
In a young patient who was vaccinated to chickenpox as a child (no previous varicella infection) should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.
Which biologics for severe RA are safe in CKD4?
Most biologics, such as monoclonal antibodies, are large proteins that are not cleared by the kidneys, and thus, no dose adjustment is needed for renal impairment, and can be used in advanced stages of CKD. Keep in mind among tsDMARDs that the JAK inhibitors do have a renal dosing adjustment require...