Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In what clinical situations would you favor IM methylprednisolone over a short oral prednisone taper for managing an RA flare?
I am not an RA expert; however, I am well-versed in the use of IM steroids for flares.After Dr. Petri's FLOAT study in SLE (Danowski et al., PMID 16395750), we have utilized IM steroids instead of daily PO prednisone as our "go-to" treatment of choice as much as we can over Medrol dose packs and QD ...
Does significant eosinophilia (8-44%) in a patient with suspected granulomatosis with polyangiitis (GPA) based on sinusitis, pulmonary nodules and positive PR3 change your management approach?
This is an important question because at times the distinction between GPA and EGPA can be difficult to make. In general, I would rely on clinical symptoms as a key distinguisher. For example, sinusitis in GPA differs from that of EGPA, with the former often causing crusting, erosions/necrosis on EN...
What's the best approach for severe calcinosis cutis in a patient with dermatomyositis who is unresponsive to diltiazem and colchicine?
Calcinosis cutis remains one of the most frustrating, typically recalcitrant manifestations of DM for both patients and physicians.Like Dr.@Dr. First Last, I also find that while there have been multiple case reports or small trials of various regimens published, the disappointing real-world variabi...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
What is the clinical significance of a low titer RNP, negative Sm, but Sm/RNP that is very high titer?
Important question as I've seen clinicians incorrectly interpret anti-Sm-RNP as anti-Smith antibody.The different autoantibodies (RNP, Smith, Sm/RNP) react to different antigens as follows: Anti-RNP can react to multiple components (antigens) of the U1 small nuclear RNP particle (snRNP), Anti-Smith ...
Do you routinely recommend antibiotic prophylaxis for routine dental cleaning in patients taking mycophenolate mofetil?
The most recent AHA and ADA guidelines continue to recommend antibiotic prophylaxis prior to dental procedures for patients at high risk of developing endocarditis (Goff et al., PMID 31728507). Additional recommendations from the ADA include avoiding routine dental care for the first 6 months after ...
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.
In what clinical situations do you consider azathioprine for treatment of inflammatory arthritis?
Azathioprine (AZA) is among the oldest pharmacologic immunosuppressive agents in use today. Initially developed as a long-lived prodrug of 6-mercaptopurine (6-MP), it was quickly found to have a more favorable therapeutic index. Gertrude B. Elion (Winner of 1988 Nobel Prize in Medicine for “importa...
What is the clinical significance of elevated serum complement (C3 and/or C4) levels?
I have always considered elevated complement levels to be an acute phase reaction and an indication of inflammation, be it infection or cancer, similar to the ESR and CRP. Recent data have linked these elevated levels with obesity and metabolic syndrome. We have known for years that levels of C3 and...
In a patient with sicca symptoms and SS-B antibodies only, can a minor salivary gland lip biopsy with lymphoid aggregates, but also scattered areas of acute neutrophilic inflammation be consistent with Sjogren's Disease?
I agree with @Dr. First Last and cannot speculate on the neutrophils.I'd also like to point out that a French study showed that only 1% of isolated anti-SSB patients had Sjogren's disease, SjD (Jardel et al., PMID 28931060); all others had other autoimmune diseases, neoplasia, infection, and solitar...