Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach decision-making around initiation of osteoporosis therapy in patients with advanced dementia?
Great question, there are many things that I consider. First, I limit consideration of osteoporosis therapy to patients who have a life expectancy of 1 year or more. This is because the time to benefit from a bisphosphonate is estimated to be about 12 months (Deardorff et al., PMID 34807231). Assumi...
In a young patient who was vaccinated to chickenpox as a child (no previous varicella infection) should the patient receive a shingles vaccine prior to starting Rinvoq?
Yes. The vaccines are different and current vaccine is to prevent zoster for patients who have been previously exposed to varicella or vaccinated for varicella.
Which biologics for severe RA are safe in CKD4?
Most biologics, such as monoclonal antibodies, are large proteins that are not cleared by the kidneys, and thus, no dose adjustment is needed for renal impairment, and can be used in advanced stages of CKD. Keep in mind among tsDMARDs that the JAK inhibitors do have a renal dosing adjustment require...
Is there an evidence-based consensus on CT-derived Hounsfield unit thresholds for opportunistic assessment of osteoporosis, and how should such measurements be applied when DXA results are inconclusive or do not meet diagnostic criteria?
Per the International Society for Clinical Densitometry's official positions: "Opportunistic CT-based attenuation using Hounsfield Units (HU) can be used to estimate the likelihood of osteoporosis (L1 HU < 100) and normal (L1 HU > 150) bone density to support decisions regarding bone health assessm...
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...
What are the reasons for SLE specific labs to turn negative?
I agree and appreciate the answers by Dr @Dr. First Last and Dr @Dr. First Last. My answer may be stating the obvious, but I think it is important to mention that lupus is not infrequently over-diagnosed and overtreated. Serologies are sometimes over-interpreted with low-titer antibodies labeled as ...
Do you recommend chronic oral suppressive antibiotics after initial intensive treatment of 6-8 weeks in patients with culture-negative prosthetic joint or bone infections with retained hardware?
Another one of those questions without a clear-cut answer. Several retrospective, uncontrolled papers (I should know. I’ve co-authored one myself) suggest this practice is “helpful”. BUT, virtually all these observations are retrospective with relatively short-term follow-up (often 1 or 2 years), an...
How do you approach management and monitoring of a patient with features suggestive of early or incomplete antisynthetase syndrome (mechanics hands and positive antisynthetase antibody) but no objective evidence of myositis, arthritis, or ILD at presentation?
Anti-Ha is a very rare antibody, and its positive predictive value is low, particularly when relying on line blot or multiplex bead assays. Especially in the setting of a high ANA titer, a low-level anti-Ha signal may represent cross-reactivity or a false positive, as anti-Ha antibodies are cytoplas...
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...