Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In patients with lupus nephritis, and MAHA with positive anti-phospholipid autoantibodies, what are the considerations to use or not use anti-coagulation therapy?
I support anticoagulation and C5 inhibition for such patients if they are not adequately responding.
Which osteoporosis medications are safe to offer a patient with severe osteoporosis who is strictly vegan?
It would be helpful to know what severe osteoporosis means and what the T-scores are in the hip and spine. For patients who are strictly vegan, I would put them on an appropriate osteoporotic medication, making sure that they have an adequate calcium intake either from their diet or supplements, alo...
Do you counsel patients differently about the risk of radiation induced malignancy when you are treating a proximal joint (hip) vs a distal joint (elbow) for benign conditions such as OA?
The mentality for this must change from radiation oncologist thinking to radiation medicine thinking. There have been no documented cases of malignancy from LDRT treatment of OA. Those who worry about the spine reference old studies giving 20 Gy in 5 fx with an open field pre-linac era. This is not ...
What is your approach to immunomodulatory treatment in patients with Sjogren's syndrome who have active serologies (i.e. elevated ESR, hypergammaglobulinemia, hypocomplementemia) but minimal symptoms?
Hypergammaglobulinemia and hypocomplementemia are risk factors for lymphoma in the setting of Sjogren's Disease (SjD), as well as cryo, IgM kappa, lymphopenia/neutropenia, RF+, asymmetric parotid swelling and disease activity (Nocturne et al., PMID 26606524). Therefore, even with "minimal symptoms" ...
How has the new data regarding long-term follow-up of degenerative meniscal tears vs surgery changed your management approach in these patients?
Degenerative meniscus tears are a common finding on MRI in our older patients. A challenge lies in determining if that finding is the cause of the patient's symptoms. When deciding whether to send for surgical consultation, I query about mechanical symptoms (catching, locking, or giving way) and/or ...
How do you approach folate supplementation for methotrexate-related side effects?
All MTX users should be taking some form of folate supplement. Either daily folic acid or weekly folinic acid are used and generally are effective. Tracking the RBC MCV is one way to ensure that patients are receiving adequate folate supplementation.The question has been raised whether folate supple...
How would you approach using the new vagus nerve stimulator for patients with RA?
Vagus nerve stimulation (VNS) may be a consideration for treating those patients with RA who have disease that is either resistant to multiple DMARDs and biological therapies, or where the risk of immune suppression significantly outweighs the potential benefits of our standard approach to managing ...
How do you use hydroxychloroquine in patients with lupus nephritis on hemodialysis or peritoneal dialysis?
After starting dialysis, other lupus manifestations frequently become clinically inactive. However, there is still a subset of patients who have clinical or serologic activity. Prior studies have shown that < 6% of lupus patients remain clinically active 5 years after starting dialysis, < 25% remain...
What Barrett's Esophagus screening protocol do you follow for patients with scleroderma given the increased risk of reflux and esophageal stasis?
This is an excellent question and is probably also relevant to mixed connective tissue disorder (MCTD) and overlap syndromes. My answer is a poor one - to my knowledge, we just do not have the data to guide us. I would certainly be more vigilant, but do not have a set protocol other than that for BE...
How do you approach immunosuppression in patients with rheumatoid arthritis and newly diagnosed bladder cancer who willl be starting intravesical BCG therapy?
I agree with Dr. Cappelli but there is an additional layer to the question. The concern is not just with efficacy of BCG treatment for bladder carcinoma when on these medications. There is the concern than anti-TNF therapy may increase the risk of dissemination of BCG, analogous to the experience wi...