Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you use bone turnover markers to assess medical adherence in patients treated for osteoporosis?
I find the bone remodeling markers very helpful. First and foremost, I want to be sure that if I am going to put a patient on an antiresorptive medication that the patient has evidence for high bone turnover over i.e., increased osteoclastic activity. If the bone remodeling markers for both bone for...
How, if at all, do you incorporate techniques such as mindfulness into your discussions with patients who have chronic pain, particularly if they are on long-term opioids?
I do use the Oregon Pain Management website with my chronic pain patients, and if they select the mindfulness tile, I go over this with them and refer them to our embedded behavioral health provider. I also teach the "square breathing" technique quite often to anxious patients with or without pain, ...
How do you approach adjusting insulin pump settings in patients who have received intra-articular corticosteroid injections?
Managing steroid-induced hyperglycemia in patients with diabetes has always been a difficult problem, and guidelines are hard to come by. Glucocorticoids cause increased insulin resistance and an increased need for insulin. The steroid effect on glucose is greater in the post-prandial state than the...
What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?
This is an important concept because anyone using tocilizumab will eventually wrestle with this question. The question, though, does not tell you whether this is the first time a practitioner sees the liver enzyme elevation, or how high the liver enzymes rose. Since everyone should have had a lipid ...
How do you approach managing nausea and GI side effects when initiating methotrexate?
There are several strategies to minimize nausea and gastrointestinal symptoms with the use of methotrexate. The medication can be taken with food, just not with caffeine. The dose can be split throughout the day it is taken such as half the dose in the morning and the other half in the evening. The ...
Is it necessary to prescribe a steroid taper after two weeks of high-dose prednisone (60 mg daily)?
Interesting question. Not being an endocrinologist, I don't have the expertise to advise but the reference below makes the statement that even short-term steroids can be an issue. I suspect that if you have to stop abruptly from 60 mg daily for 2 weeks, it would probably be fine in most instances bu...
How do you approach the frequency of DEXA scan monitoring for older adults on bisphosphonate therapy during the course of therapy?
Depends who you read. ACP: Recommendation 4: ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women. (Grade: weak recommendation; low-quality evidence) [1] Monitoring wasn't addressed in the 2023 update. ACR: For adults continuing...
Would you proceed with renal transplant in a patient with lupus nephritis who has progressed to ESRD and is clinically stable, but has persistently elevated dsDNA and low complements despite appropriate doses of hydroxychloroquine and mycophenolate?
Short answer: Yes—if the patient’s clinical lupus is quiescent for at least 6 months, it is reasonable to proceed with kidney transplantation even in the presence of persistent serologic activity (e.g., low complement, elevated anti-dsDNA).Why this matters: Transplant > Dialysis: Patients with LN-ES...
How would you approach the upfront management of a patient with acute unilateral vision loss with strong clinical risk factors for both cardioembolic stroke and GCA if an expedited MRI is not possible due to the presence of an AICD?
I'm definitely not an expert in this topic, but you have many clinical tools to increase/decrease your clinical suspicion for GCA vs. cardioembolic stroke. Some things I would ask: Is this patient currently in Afib? What's their CHADSVASC? Are they anticoagulated? Can we get a TTE to check for vege...
In patients with RA on methotrexate and a TNF inhibitor who develop PJP pneumonia, how long do you hold immunosuppression before restarting therapy?
I would typically hold immunosuppression until the patient has completed therapy unless they had significant respiratory failure, in which case I would await full recovery. The patient should be placed on appropriate PJP prophylaxis prior to resuming therapy.