Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you counsel a patient with Sjogren's and extremely dry mouth who is losing their ability to taste food?
Agree with Dr. @Dr. First Last, and we cannot overemphasize the candidiasis part. Have a very low threshold for treating candidiasis while at the same time maximizing salivary stimulation (pilocarpine, cevimeline, bethanechol). When severe xerostomia occurs, as in the question, atypical presentation...
Do you check mycophenolate levels in patients prescribed mycophenolate who present with a lupus nephritis flare?
In general, I tend to shoot for an induction dose (3 grams) if I am using Cellcept with steroids for a flare, unless I am doing multitarget therapy or there are side effects such as GI symptoms or cytopenias. In those cases, I lower the dose to 2 grams (1000 mg BID). If there is concern for unsatisf...
What is your approach to a patient with RF+/CCP+ rheumatoid arthritis that was previously on TNFi now with high-titer ANA and dsDNA (crithida 1:2560), +chromatin, +histone?
This scenario reads like TNF inhibitor drug-induced serological lupus. The first clinical issue is: are there accompanying symptoms or signs of systemic lupus erythematosus (SLE) beyond the underlying inflammatory arthritis, which would be better attributed to the seropositive rheumatoid arthritis (...
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...
When discontinuing Denosumab after more than 2-3 years of therapy, when do you recommend giving the first dose of zoledronic acid?
My practice has been that after 2-3 years of denosumab, I wait 6 months and then start zoledronic acid.
Are there benefits to adding IL5/IL5 receptor blockade in patients with vasculitic manifestations of EGPA?
While IL-5/IL5 receptor blockade has been shown to be efficacious in treating "eosinophilic" manifestations of EGPA, including asthma and nasal polyps, there are real-world studies that demonstrate its effectiveness in what we consider "vasculitic" manifestations of the disease as well. I personally...
What is your treatment approach for pregnant patients with IgA nephropathy who have worsening proteinuria during the first trimester?
Difficult question to answer without more details, but I would consider the following factors: One is whether it appears that the IgA is active. When was the last biopsy, and how much hematuria is present? Two would be if this is 'worsening proteinuria' is really just the first time proteinuria has ...
How would you counsel a patient with relapsing polychondritis who is considering a turbinectomy for nasal obstruction regarding potential risks and disease-related complications?
Thank you so much for thinking so carefully about this!!.<3 <3 When I talk with a patient who has relapsing polychondritis and is considering a turbinectomy for nasal obstruction, I try to acknowledge how difficult and frustrating these symptoms can be, while also making sure we keep their safety a...
Will you give a trial of tirzepatide in patients with PsA and obesity who have a partial response to bDMARD rather than switching their immunosuppressive regimen?
I don't believe the data on the magnitude of the benefit of GLP-1 agonists in arthritis symptoms is sufficient to suggest that adding one of these agents would be preferable to changing DMARDs in a patient with inadequate response.
What biologic or conventional/synthetic DMARD would you use as a steroid sparing agent in a patient with GCA and a history of diverticulitis?
This is an important question. Both IL-6 inhibitors and JAK inhibitors have a risk of bowel perforation which is increased in patients with a history of diverticulitis, therefore, these agents must be used with great caution in such patients and alternative therapies are often preferred.First, it's ...