Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach diagnosis and management of orbital myositis?
Orbital myositis is an umbrella diagnosis that includes a wide range of potential underlying conditions. Patients with this presentation are often first evaluated by neuro-ophthalmology to exclude causes such as isolated orbital myositis, myasthenia gravis, thyroid eye disease, infection, and diabet...
Based on Together-PsA, would you favor starting all patients with PsA and comorbid obesity on combination therapy with tirzepatide + bDMARD or will you pursue initial bDMARD monotherapy with tirzepatide rescue in the event of bDMARD non-response?
In looking at the Together-PsA data, this was a challenging cohort to treat, and a reasonable increase in treatment response was seen with combination therapy. Multiple studies have shown that obese psoriatic arthritis (PsA) patients are less likely to achieve minimal disease activity (MDA) and have...
What is your approach to managing sclerosing mesenteritis (mesenteric panniculitis)?
I have seen and followed dozens of patients with this diagnosis. As noted above, it is important foremost to be sure of the diagnosis. Mesenteric panniculitis can be part of the IgG4 associated spectrum and so a biopsy is useful if it can be done safely. The other disease in the differential is carc...
What baseline work-up or "staging" do you do in patients with a new diagnosis of Sjogren's (i.e., PFT, cryoglobulins, complement, RF, UA)?
The baseline workup I like to do in patients newly diagnosed with Sjogren's are the following lab tests with rationale: ANA (almost all patients have a high titer ANA that is positive - typically it is a speckled pattern Extractable nuclear antigen (ENA) testing looking for SSA (anti-Ro antibody) +/...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
How do you approach patients with fibromyalgia who are reluctant to consider a psychiatric component to their illness but present with clear mood or anxiety symptoms?
Since patients with fibromyalgia (FM) are often stigmatized and worried that clinicians think “it is all in my head,” it is important to discuss FM treatment and mental health referral from a biopsychosocial perspective. This might include introducing concepts such as the pain/depression dyad, centr...
Is there any value in nonspecific inflammation seen on a salivary gland biopsy for making a clinical diagnosis of Sjogren’s disease in a seronegative patient with sicca symptoms (ie. chronic sialoadenitis with focus score 0)?
Unfortunately, nonspecific inflammation is unhelpful. In patients classified as having Sjogren's, the minor salivary gland biopsy will have a focus score of 0 in about 20% (Sharma et al., PMID 31092717). So you cannot rule out Sjogren's with a negative/non-specific biopsy. To meet the 2016 ACR/EULAR...
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
Do you think we can extrapolate the results of TOGETHER-PsA and expect similar results and safety when adding Tirzepatide to another IL-17 inhibitor or to a bDMARD with different mechanism of action?
Yes and no. We don't have hard randomized controlled trial (RCT) data with biologic disease-modifying antirheumatic drugs (bDMARDs) other than ixekizumab at present. However, if we extrapolate data from prior weight loss studies in psoriatic arthritis (PsA) and psoriasis (PsO), it would be reasonabl...
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...