Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
How would you approach a patient with class III and V lupus nephritis, already on HCQ, MMF, voclosporin and losartan, but has continued proteinuria not yet attaining complete renal response?
Few things are more complicated than lupus nephritis, and this question is not answered easily. It depends on hematuria, Cr, proteinuria, C3, C4, dsDNA, and systemic symptoms. So, it depends on what I think is causing the incomplete clinical response. If I believe it is the class V lesion, I would g...
Would you order a repeat DEXA scan 1 year later for a kidney transplant patient who had an initial DEXA scan within the first 6 months post-transplant showing osteopenia but no history of fractures, and who has been stable on glucocorticoid-free immunosuppressive therapy?
I agree with Dr. @Dr. First Last. Bone metabolism in renal transplant is woefully shy of good data. My opinion is to monitor Vitamin D levels, provide appropriate supplementation, and monitor PTH levels, using cinacalcet as needed. My target level for PTH is 1-2x the upper limit of normal, also base...
Assuming lab accuracy, what are some of the hallmarks and symptoms that would lead to a diagnosis of ANA-negative lupus as opposed to any other autoimmune condition?
I would not make an initial diagnosis of ANA-negative systemic lupus erythematosus (SLE) lightly, especially since there are so many mimics of SLE. However, it does occur, even in early, untreated patients. Even some of the best lupus centers in the world (SLICC) have a 6% prevalence of ANA-negative...
When do you recommend initiation of targeted therapies in active RA with history of malignancy?
In patient with RA and a history of malignancy, I generally recommend the same therapy that I would recommend in the absence of a malignancy history. This is consistent with the most recent ACR guidelines for the management of RA (Fraenkel et al., PMID 34101387). Consistent with FDA labeling, I'd ge...
How would you approach the treatment of erosive inflammatory arthritis (RA or SpA) in a patient with multiple sclerosis on ocrelizumab who has failed csDMARD therapy?
This is a challenging situation to confront, however, as more non- rheumatological illnesses are being managed with biologics, we will be facing this issue with greater frequency. Regarding multiple sclerosis (MS), one should be aware that the major metabolite of leflunomide, teriflunomide, is a bra...
Do you always perform salivary gland biopsy to confirm the diagnosis In patients with suspected seronegative Sjogren's syndrome?
I often struggle with the decision of obtaining a biopsy in suspected Sjogren's in a person who is seronegative, when the main issue is dryness, and the main reason is that I wonder if it will make a difference in management. When I was a Rheumatology fellow, I was taught to give Hydroxychloroquine ...
What is your approach to refractory oral ulcers in SLE?
Would not consider only trying HCQ as being refractory. Many more lupus medications to be tried! Azathioprine, MMF, Methotrexate, and Benlysta would all be under consideration. I presume their labs show some aspect of active SLE.
Would you choose bimekizumab over other IL-17 inhibitors in patients with increased levels of disease related pain and poor functional status?
In the absence of head-to-head trials, I hesitate to make a recommendation regarding which IL 17 inhibitor is better in this situation. It is also very unlikely that the makers of the three IL 17 inhibitors would conduct such trials. Network meta analysis and matching-adjusted indirect comparison ar...