Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider prescribing a JAK inhibitor for a patient with a history of DVT who is on chronic anticoagulation, or would the thrombotic risk deter you?
There is no definitive answer here except to say that most rheumatologists would likely explore and employ all other available options prior to selecting the higher-risk one in this type of patient. But, ultimately, if all other options were exhausted and unsuccessful, you still have a patient with ...
What is your approach to treatment of macrolide-sensitive localized bone/joint MAC disease?
Agree with the above answers. Obviously, no strong clinical studies on duration and outcomes. At NJH, we typically recommend: Aggressive debridement/resection, Treat with appropriate antimicrobial therapy (in macrolide-S MAC, then AZM/EMB/Rifamycin +/- IV AMK) for a minimum of 6 months total, but a...
How do you screen rheumatoid arthritis patients for lung disease (modality, frequency, patient selection)?
Theoretically, we are supposed to screen these patients obtaining a baseline chest X-ray before starting DMARD therapy. As I remember, these guidelines were formulated when MTX was still blamed for MTX lung disease although presently, even the presence of underlying ILD is not necessarily a contrain...
For what sort of SLE clinical profile do you favor anifrolumab beyond patients with prominent skin manifestations?
Skin disease is obviously the primary clinical manifestation. I will also prescribe it to patients with arthritis, pericarditis, mucosal disease, and hair loss. I await the results of the trial in lupus nephritis. I have an n of 1 experience with a patient with long-term high anti-dsDNA and low comp...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...
How do you counsel patients with RA stable on csDMARDs on whether to attempt tapering or not?
It is important to recognize that this counseling is highly individualized and that factors such as risks of medication toxicity, age, comorbidities and disease severity all play a part. However, several studies have demonstrated a significantly increased risk of RA flares and radiographic progressi...
In a patient with Class IV lupus nephritis and cardiomyopathy who has received cyclophosphamide, how do you approach the use of biologics such as belimumab or voclosporin in the setting of ongoing proteinuria?
Voclosporin and belimumab have both been shown to have efficacy in the treatment of lupus nephritis, and are exciting options to consider, as also recommended in the ACR guidelines. One of the key questions for ongoing proteinuria is the degree of active disease vs chronicity, and the role of a (rep...
How do you interpret DXA results in cases where there is discordance between normal hip and spine BMD with abnormal one-third radius BMD?
This is an interesting question. To my knowledge, there are no fracture prediction models based only on forearm bone density values so my response is my opinion and not evidence-based. Firstly, we always rule out hyperparathyroidism when there is forearm bone discordance compared to spine and hips s...
How do you approach therapy for severe osteoporosis after an initial 12 months of romosozumab?
After 12 months of romosozumab, most likely the patient will still need additional therapy. If you can get a bone mineral density, that can guide you into what the best next medication can be. If the patient still has significant osteoporosis or fracture during the treatment with romosozumab, I woul...
How would you manage a patient SLE who is planning pregnancy and has serologically active disease (elevated dsDNA, low C3/C4), mild arthritis, and is otherwise asymptomatic on hydroxychloroquine 200 mg BID and methotrexate 15 mg weekly?
Options I'd consider would be sulfasalazine and/or azathioprine, as mentioned. I think the question is will SSZ+HCQ be enough for her SLE or will AZA+HCQ be enough for her arthritis? Could certainly add Belimumab to her HCQ, although it has a much longer onset of action and certainly less pregnancy ...