Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What biologic or conventional/synthetic DMARD would you use as a steroid sparing agent in a patient with GCA and a history of diverticulitis?
This is an important question. Both IL-6 inhibitors and JAK inhibitors have a risk of bowel perforation which is increased in patients with a history of diverticulitis, therefore, these agents must be used with great caution in such patients and alternative therapies are often preferred.First, it's ...
What is your approach to treatment of airway involvement, such as recurrent bronchial stenosis, in relapsing polychondritis?
Depending on the location of airway involvement from the subglottic area to the trachea and central airways, options include cryo-spray ablation, balloon dilation, APC/Laser ablation (less favored), Kenalog injection and airway stenting. Typically, combined modalities are more effective than single ...
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...
What is a reasonable stepwise approach to diagnostic imaging when there is ongoing concern for cardiac amyloidosis?
Abnormalities on CMR are not diagnostic of cardiac Amyloidosis. Although LGE, abnormal ECV, and abnormal T1 are findings commonly seen in Cardiac amyloidosis, the absence of one or more does not rule out amyloid. In the setting of increased LV thickness and clinical suspicion of amyloid, I would hav...
Is there any expanded diagnostic workup that you pursue for a young female patient with gout?
In 45 years of practice, and with a strong focus on gout, I can count the number of premenopausal women with gout I’ve seen (or, perhaps better stated, recognized) on one hand. Of the last two, one had chronic renal failure due to acute kidney injury incurred secondary to an alcoholic binge a few ye...
What do you recommend to patients when they are having an acute flare of fibromyalgia symptoms?
Great, this is a really important area and unmet need in the field of fibromyalgia management. Unlike other nociplastic disease states (e.g., migraine), there are no rigorously studied abortive therapies to rapidly treat a flare of centralized pain. Indeed, all the therapies we use for FM are intend...
How long do you continue rituximab in patients with ANCA associated vasculitis who have achieved remission?
My approach is to use rituximab every 6 months for remission maintenance for at least 2 years. Past that point, a lot depends on the individual patient circumstances. For patients who have already suffered substantial organ damage, for whom another flare could be catastrophic (e.g., a patient with s...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...