Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In an infant whose mother resumes TNF inhibitor therapy (e.g., adalimumab, infliximab, certolizumab) after delivery and is breastfeeding, do you recommend delaying live vaccinations?
IgG-based biologic therapies - including TNF inhibitors - are all considered compatible with breastfeeding, since IgG passes only minimally into breast milk. Given these agents are proteins, the minimal drug that is transferred is unlikely to remain intact (or active) with passage through the infant...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
Do you routinely screen for cardiovascular risk factors in a patient with moderate-to-severe psoriasis?
Review of systems. Depending on age, consider lipids and HbA1c if no data for the past year.
Would you use a parathyroid hormone analog for treatment of osteoporosis in a patient with mildly elevated AlkPhos of unclear etiology?
I would be hesitant to administer an anabolic in this setting without first delineating the reason for an elevated AlkPase. I would suggest starting with sorting out the source of the AlkPase (i.e., bone, liver, or gut with measuring bone-specific AlkPase, G-GGT levels, and possibly a liver ultrasou...
What cosmetic options can you provide to patients with facial discoid lupus that seems stable?
Procedures such as botulinum toxin A, fillers, and autologous fat grafting can be considered in patients with discoid lupus if the disease has been clinically stable, typically meaning no new lesions or active inflammation for about a year. Light-based vascular treatments such as pulsed dye laser ca...
Do you utilize cytokine panels to guide treatment of patients with EGPA?
Whether biomarkers can guide treatment decisions or predict disease relapse is a critical area of study in ANCA associated vasculitis. However, efforts to identify biomarkers that are predictive in EGPA are at an early stage currently. There have been multiple negative studies of biomarkers being ab...
How would you apprach a SLE patient who is planning pregnancy on hydroxychloroquine with a high titer dsDNA who cannot tolerate azathioprine and whose only symptom is arthralgia?
In an SLE patient planning pregnancy whose only clinical manifestation is arthralgia, hydroxychloroquine monotherapy is appropriate. During the pregnant and non-pregnant state, additional immunosuppression is not indicated for a high titer dsDNA; rather, monitoring for organ manifestations is approp...
What is in the differential diagnoses for isolated bilateral tarsometatarsal joint erosions in the absence of other clinical or serologic evidence of systemic inflammatory arthritis?
Post-traumatic injury is the most common cause, especially mid-foot sprains and fractures, although not usually bilateral unless there is a predisposition such as high arches and osteoarthritis (OA) that can occur due to mechanical stress. Erosive OA can cause these findings, although more commonly ...
What is your approach to a patient with generalized morphea, no systemic involvement but a positive RNA Polymerase III?
I would perform age-appropriate cancer screening given the link between RNA pol III and cancer. Otherwise, I would simply monitor for onset of systemic sclerosis or other autoimmune disease symptoms.
What is your approach to escalating therapies for stiff person syndrome that is refractory to IVIG and steroids?
Step 1: Make sure the diagnosis is correct, especially if seronegative or very weakly positive for GAD65 antibodies.Misdiagnosis of SPS is common and diagnostic criteria have been recently proposed (Reference 1). Patients who complain of subjective stiffness/muscle spasms, but do not have objective ...