Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
If a patient is legally blind and on hydroxychloroquine, do you still recommend follow up with ophthalmology to monitor for hydroxychloroquine retinal toxicity?
A patient who is legally blind but taking hydroxychloroquine absolutely needs to be monitored by an ophthalmologist. The usual definition of legal blindness in the United States is vision no better than 20/200 in the better-seeing eye. But 20/200 is far better than say counting fingers (the ability ...
What is your approach to further work-up and management of neutropenia in patients with SLE/RA overlap?
This is an interesting situation that comes up in the routine evaluation of patients with rheumatoid arthritis and other autoimmune syndromes. The normocellular bone marrow suggests a peripheral destruction, in general, and raises some concerns for antibodies directed against neutrophils. These are ...
Have you used JAK inhibitors with TNF blockade at the same time?
Generally, no. For three reasons: I find the addition of a JAK inhibitor to a TNF inhibitor to be too immunosuppressive with a high risk of infection and/or malignancy. If I am choosing a JAK inhibitor, it would serve to "replace" the TNF inhibitor usually, so I don't see a strong indication to sta...
How would you manage axial spondyloarthritis in a patient who was doing well on TNF inhibitor therapy then developed a new solid organ malignancy while on treatment?
The story here is an important one. I was able to discuss this with @Dr. First Last, who supplied important insights. Most of the good (and bad) data supporting what to do when your patient had a prior malignancy in remission or who develops one on treatment comes from experience with treating rheum...
When screening for malignancy, do you order CT with contrast (or) both with and without contrast?
I think the best way to think about this is to assess what each scan shows. A CT with oral and IV contrast is very good for assessing details between soft tissues and blood vessels. A CT without contrast is better for assessing for renal stones and for fractures, especially small insufficiency fract...
Should special precautions be taken patients with Ehlers-Danlos syndrome receiving radiation therapy?
Not all EDS is the same. Most commonly, an EDS patient these days is a clinically diagnosed patient with hypermobile joints, possibly stretchy skin, and possibly chronic pain syndrome. That is a very different picture from vascular EDS with a COL3A1 mutation, which is rare and would have the extreme...
How do you approach management of a patient with multiple lung nodules and low titer +CCP but no active joint symptoms suggestive of RA?
In the absence of other clinical symptomatology, I would favor close observation and follow-up in this case as there is no established diagnosis and repeat CT, PFT’s in 3 to 6 months. Details of initial evaluation should include PET-CT to exclude malignancy but also to investigate other organ system...
How would you manage a patient with discordant TBS adjusted T-score and traditional T-score?
The ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis) and IOF (International Osteoporosis Foundation) recommend the use of TBS-adjusted T-scores to help guide osteoporosis treatment decisions. However, this recommendation is based on a single research study and therefore may...
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
What circumstances would drive you to consider using an oral IL-23 inhibitor over parenteral options for the management of psoriasis and/or psoriatic arthritis?
Psoriatic arthritis is a heterogeneous disease and the choice of therapy is driven by many factors.The most important factors in the decision tree are whether the patient has 1) axial disease and/or 2) severe psoriasis.Additional Considerations include: prior therapies, extramusculoskeletal manifest...