Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...
How do you approach the treatment of patients with Ehlers-Danlos hypermobile type with chronic muscle spasms with minimal exertion?
You accept that EDS is a genetic connective tissue disorder and not a rheumatological issue. You check hormones and vitamins to ensure they are in range: especially Mg with the cramps. Some EDS patients find working with an EDS physical therapist is beneficial: the goal being to learn how to exercis...
In a patient with gout previously treated with pegloticase who then discontinued therapy, can pegloticase be safely and effectively restarted?
It depends on the reason for discontinuation of Pegloticase therapy in the first place, since efficacy and safety data varies with it.Pegloticase can be safely and effectively restarted if the initial discontinuation was not due to a loss of efficacy or a severe infusion reaction, and should be done...
How would you manage axial stiffness without pain in an elderly gentleman with a distant history of HLA-B27+ axial and peripheral spondyloarthritis, now with SI joint fusion, no peripheral arthritis, normal inflammatory markers, and no response to TNF inhibition?
Based on the history and lack of response to anti-TNF therapy, I suspect the patient does not currently have active inflammatory disease but likely sequalae of prior damage and degenerative spinal disease as a cause of his stiffness. A trial off of the biologic would help assess if the medication is...
What is your treatment approach when managing patients with relapsing lupus nephritis who previously achieved remission with mycophenolate and steroids?
Remember that each lupus nephritis (LN) flare is accompanied by permanent loss of nephrons, as much as a third! Each flare increases the risk for poor response (Perez-Arias et al., PMID 36318456). Relapse is not to be taken lightly.I am a big believer in considering combination therapy as initial th...
How will you approach tapering of therapy in a patient with PsA who has responded well to tirzepatide and ixekizumab and has maintained disease remission for several years?
This is a difficult question to answer based on current data. While tapering is a standard strategy for DMARD therapies in many rheumatic diseases, many studies show that successful tapering or therapy discontinuation is not possible for most patients. If we are evaluating ixekizumab alone, few pati...
What would be your recommendation for treatment of worsening lung disease in a patient with long-standing scleroderma after long-term mycophenolate therapy which is no longer an option due to side effect/intolerance?
Someone who has been on long-term Mycophenolate for interstitial lung disease and has had stabilization or improvement in their lung function and then is unable to tolerate the medication may be able to be switched to mycophenolic acid sodium (myfortic) which is often less toxic and better able to b...
How often are you repeating screening PFTs in patients with SARDs who have 3 or more years of normal or stable PFTs?
The answer to this question is complex and needs to be tailored to the individual patient’s risk for ILD and the particular SARD.Approximately 30-40% of patients with systemic sclerosis (SSc) will develop ILD, typically within the first 5 years after the first non-Raynaud’s manifestation and rarely ...
How do you counsel patients who ask if there are any dietary modifications they can make to help control their autoimmune disease?
I send patients to a website called nutritionfacts.org. This is a non-profit website that reviews medical literature related to nutrition and diseases. It was founded by Dr. Greger and he is not trying to sell anything which I appreciate. He has bite-sized videos on anything you can think about rela...
In patients with livedoid vasculitis and chronic venous insufficiency on rivaroxaban, what therapeutic strategies—beyond compression and topical care—are safe and effective for controlling pain, ulceration, and edema?
My experience has been that aspirin 365 mg, plus persantine or trental daily, plus leg elevation for 45 min or so in mid-afternoon, will produce pain relief and onset of healing within about two weeks. Only infrequently have I had to resort to metformin as an added medication or use both trental and...