Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach the significance of +RNP III antibody in a patient with positive ANA but no other signs or symptoms of systemic sclerosis?
RNA polymerase III is a specific autoantibody for a subset of systemic sclerosis associated with severe diffuse cutaneous scleroderma, renal crisis, GAVE, and a strong association with malignancy. If this antibody is identified in the absence of Raynaud's or other symptoms of scleroderma, its signif...
How do you manage episodes of Raynaud's that are frequent and bothersome in the winter months?
If Calcium channel blockers (Nifedipine extended release, Amlodipine) have been trialed already, and non-pharmacological management [including avoiding cold exposure, stress, and certain vasoconstrictive medications (e.g., beta-blockers, nasal decongestants, amphetamines, migraine drugs)] has been m...
How should rheumatologists address the impact on patients who are initially diagnosed with SLE based on positive ANA, but later reclassified as having UCTD?
I experience this question a bit differently. Patients who are told they have a diagnosis are frequently living in a certain mindset with a certain expectation and possibly even a fear of the alteration of their life. The patient with a diagnosis trusted a doctor to give them sound and honest advice...
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...
What is the recommended timing for starting denosumab after completing zoledronic acid?
6 months
How do you handle hypogammaglobulinemia detected in patients prior to maintenance rituximab infusion?
That is a good question. Adding on to Dr. @Dr. First Last's response, rituximab has been shown to cause hypogammaglobulinemia that can persist or worsen with ongoing therapy. In a study published by Barmettler and colleagues, 133 patients out of a cohort of 8633 patients had serum IgG levels checked...
How would you manage active severe psoriasis in a patient planning pregnancy, who also has psoriatic arthritis with well-controlled joint symptoms on certolizumab pegol (anti-TNF therapy)?
If the psoriasis was sufficiently limited in area that topicals were a practical solution, I'd first try to assure that the prescribed topical steroids were being used well. Poor adherence is a common issue with topical treatment. Phototherapy might be my next choice. I feel comfortable prescribing ...
Do you check IgA levels before starting IVIG for other autoimmune conditions?
Whereas it is not mandatory to check IgA levels before starting IVIG, it is prudent to do so in non-urgent situations since the patients with IgA deficiency, especially those who have developed anti-IgA antibodies, are at an increased risk of severe hypersensitivity or anaphylactic reactions from IV...
Over what timeline do you typically try to escalate your LN patients to triple therapy?
The new recommendation is "Early Quadruple Therapy" per the 2025 EULAR Lupus Nephritis Guidelines announced during a presentation at EULAR 2025 by Dr. Dimitrios Boumpos.Kudos to EULAR! They recommend this to: increase remission rates reduce the need for steroids with these steroid-sparing agents red...
What treatment strategies would you utilize in a patient with newly diagnosed HLA-B27+ axial spondyloarthritis (with active and chronic sacroiliitis on MRI) and recent diagnosis of MS that is well-controlled MS ocrelizumab given the need to avoid TNF inhibitors?
This is a very challenging scenario. On one hand, TNFi are generally unsafe for MS due to demyelination risk, and on the other hand, anti-CD20 therapies for MS are linked to new AxSpA, but B-cell depletion might also benefit AxSpA. Thus, management requires specialized care in balancing both disease...