Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you work up patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance?
Myoglobin may originate either from cardiac or skeletal muscle; therefore, I would first try pinpointing the origin with troponins and CK fractions. I would work up the exercise intolerance with a non-ischemic forearm test to determine whether a flat lactate curve is present. In that case, I’d typic...
Is there a difference in efficacy between steroid-sparing agents like methotrexate, mycophenolate, and azathioprine in the treatment of immune-mediated myopathies?
Currently, there is no high-quality evidence favoring one immunosuppressive agent over another in the treatment of immune-mediated myopathies, as there are no head-to-head comparative trials and most available data come from small, observational, or retrospective studies. As a result, the choice of ...
How do you approach management of a patient with coexisting psoriasis and systemic sclerosis, particularly when both active psoriasis and skin tightening are present?
It depends if both diseases are considered significant and active. If so, a JAK-inhibitor would kill two birds with one stone. JAK's are already approved for psoriatic arthritis, and there is decent data for skin psoriasis as well, on par with some of our currently FDA-approved therapies. There is s...
How do you screen for colon cancer in patients with Behcet syndrome with colonic involvement?
Behcet syndrome, unlike some other rheumatologic conditions, for the most part, has not been shown to increase risk of malignancies in patients. This may in part be due to the fact that the disease tends to get milder/less severe with time and treatment. As such, colon cancer screening should follow...
What is your approach to choosing a particular advanced therapy based on patient or disease factors when initiating treatment for moderate-severe IBD?
The selection is based less on relative efficacy and safety (aside from JAKs) and more on the patient: Age, gender, family history, and co-morbidities. Younger males: more concern regarding lymphoma with thiopurines. Young women: If contemplating pregnancy would consider biologics vs small molecule...
How would you approach new-onset large vessel vasculitis in a young patient with Crohn's disease?
Patients with Crohn's Disease (or IBD) can develop features of large vessel vasculitis or even other forms of vasculitis. The first consideration in a young patient would be determining the type of vasculitis--whether there is a distribution and clinical picture suggestive of TAK. It is important to...
What are the current recommendations for the management of pediatric non-infectious uveitis?
Agree with Dr. @Dr. First Last's answer. By the time these patients see pediatric rheumatology, they have had a number of labs drawn looking for infectious and non-infectious etiologies of uveitis and have also usually been trialed on topical steroid drops (predforte or otherwise) +/- oral prednison...
When using IV TNF inhibitors, do you follow levels to determine if the current dose is adequately treating the patient?
I tend not to get levels, but rather I rely on clinical response; if partial response, often increasing dose (or shorten intervals) can provide dramatic benefit. If the prior response is lost, then consider getting levels and checking for HACAs. I often use TNFi with csDMARDs (e.g., weekly SC methot...
For a pediatric patient with juvenile spondyloarthropathy with partial response, though ongoing axial disease, on a JAKi, would you increase the dose of JAKi, add methotrexate, or switch to alternate therapy like IL-17 inhibition?
Let me first disclose that I am not a pediatric rheumatologist and would defer to one. Have NSAIDs been tried and optimized? If not, that is the best first option. In general, optimizing the dose of a medication that seems to be working is a great choice. However, I do not know what current dosage i...
How would you counsel a woman with a strong family history of thrombosis about oral contraceptives?
This can be a complex question for which there are likely no specific data or guidelines upon which to base a recommendation. ASH has published guidelines on thrombophilia testing in VTE (Middeldorp et al., PMID 37195076). They specifically recommend against testing prior to COC prescription. The ra...