Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach the management of autonomic neuropathy in a patient with Sjogren's?
Early on in working with autoimmune patients, I had access to neurogastroenterology specialists and gained an appreciation for GI dysmotility disorders. In addition to Scleroderma, Sjogren's patients frequently had documented abnormalities on motility studies. Neuro and immune abnormalities can lead...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
Is there any role for prophylactic DMARD therapy to prevent immune-related adverse events (irAEs) in patients receiving immune checkpoint inhibitors?
Excellent and timely question!There are no good studies-- but I truly believe this is where we are heading for cellular therapies and IO. I am unsure if it will be DMARDs, as lung cancer patients get premetrexed with IO and still develop irAEs-- it will more likely be bDMARDs.The reason, I believe, ...
What is your approach to management of recurrent Kikuchi-Fujimoto Disease?
My experience with recurrent Kikuchi–Fujimoto disease (KFD) is limited, as I have not managed many recurrences; however, this is the general framework I use in practice. At the time of a recurrence, I first reassess the diagnosis and consider potential mimics—particularly infection, lymphoma, and ev...
In patients with relapsing polychondritis with suboptimal response to NSAIDs and prednisone, what are strategies you use for flare treatment?
It depends on multiple variables, including organ involvement, disease activity, and associated manifestations. I would be happy to discuss it further if you would like.
What minimum clinical features or risk factors drive you to obtain a baseline HRCT in a patient with RA or Sjogren's disease?
Overall, about 10% of RA patients will develop clinically significant ILD, as will 20% of those with SjD. Those are a significant number of people, and ILD should be on our radar as clinicians. Knowledge of risk factors for ILD can help us focus on people most likely to be affected. Several risk fac...
How do you approach management of chronic cough in patients with ILD?
By the time an individual presents with ILD and cough, and fibrotic therapy has started, there’s almost no use for increasing the dose to treat cough instead of a neural modulator such as gabapentin, and if cough is interrupting sleep, low-dose narcotics. The spinoff is that narcotics may reduce dia...
Do you provide empiric doxycycline for Lyme Disease to asymptomatic patients after a tick bite who haven't developed Erythema migrans or are not sure it was an Ixodes tick?
I would base post-exposure prophylaxis upon local prevalence (unless the patient has a recent notable travel history). For example, Lyme disease is very rare in California due to the Ixodes tick's intermediate host being the Western Fence Lizard (long story short, something in their blood kills the ...
How do you weigh the risks of re-treatment with infliximab in a patient who has been off it for over a year?
To answer this question, we first need to go back in time. Treatment with infliximab has been known to elicit the formation of antibodies against infliximab. The presence of these antibodies has been associated with infusion reactions in 7-19 % of patients and may also shorten the duration of the ef...
Are there specific conventional DMARDs and/or biologics that are contraindicated in patients with alpha-gal allergy?
Here is a Q&A from AAAAI (American Academy of Allergy, Asthma and Immunology) addressing this question for etanercept and other monoclonal antibodies that are manufactured in cell lines that glycosylate with alpha-gal. The author concludes, "The risk is not zero, but likely very low".