Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What lab monitoring and frequency do you recommend in an otherwise healthy young patient on biologics for psoriasis?
Yearly QuantGold testing in low risk patients has been shown to be unnecessary and actually carries a significantly higher risk of false positive than true positive. Unfortunately, many insurers still require yearly testing. I don't know of any data to support any other yearly lab testing for the dr...
How do you make the decision to empirically treat for GCA when a patient is referred but cannot be immediately seen in clinic?
This is an important question because referrals for possible GCA are common scenarios when a rheumatologist may be asked to recommend a treatment before seeing the patient which are often challenging scenarior. The factors I typically rely on to rate the probability of GCA include: - Specific sympto...
How do you ensure that fibromyalgia is appropriately recognized in patients with Sjogrens?
I like Dr. Pisetsky et al's recent recommendation of naming this "nociplastic pain" rather than fibromyalgia. They were specifically talking about "lupus-associated nociplastic pain", but after reading their article, it should also apply to Sjogren's disease.I'd encourage everyone to read their very...
How do you counsel a patient with Sjogren's and extremely dry mouth who is losing their ability to taste food?
First, I assess if oral candidiasis is present; if so, treat. Consider if there are other cofactors that may be present, such as laryngopharyngeal reflux, B12, or Zn deficiency. If the taste buds are atrophic, you could try oral coconut oil or Vitamin E… but it’s tough. I consider, but it is hard to...
How does an incidental finding of low bone density on imaging done for another reason inform your screening approach for osteoporosis?
In patients with CKD, I would also look for changes on the plan radiographs of secondary hyperparathyroidism. For example, erosion of the distal tufts of the phalanges on hand films, erosion of the clavicle, and arterial calcification. If these findings are present, then it signifies hyperparathyroi...
How do you incorporate hyperbaric oxygen therapy into the care of patients with wounds related to ischemic ulcerations?
Hyperbaric oxygen therapy (HBOT) is intended to improve local tissue hypoxia in non-healing ulcers. Evidence for its use remains limited, primarily consisting of case reports and small case series. Most documented cases involve lower-extremity ulcers, often related to macrovascular disease. For digi...
How often do you perform nailfold capillaroscopy in your clinical practice in patients with CTD?
In an ideal world, I would perform nailfold cap on all patients (to gain prognostic information on the extent of disease progression), but this is not feasible, and nailfold cap is not always necessary from a diagnostic perspective if the diagnosis is already clear. It is most useful when the diagno...
How do you approach the diagnostic evaluation of osteoporosis in CKD when renal dysfunction limits use of certain tests or biomarkers?
DEXA is still appropriate, and if anything, would underestimate the actual bone loss. For serum biomarkers, only TRAP5B, bone-specific Alkaline phosphatase (BSAP), and PINP are not altered with renal impairment (i.e., not partially cleared by the kidneys, leading to circulating fragments that render...
What is the maximum dose (mg/kg) you will push an IV TNFi to for a patient with Takayasu arteritis who is adherent and does not have evidence of anti-drug antibodies before switching to an alternate class of therapy?
For uveitis, I have used infliximab at 20 mg/kg/dose every 2 weeks to save vision.
How do you manage hypercalcemia in an osteoporosis patient on a PTH analogue?
Teriparatide should not be prescribed to patients with pre-existing hypercalcemia or underlying hypercalcemic disorders such as primary hyperparathyroidism, as it may exacerbate hypercalcemia.[1][2][3] The Endocrine Society recommends that serum calcium be assessed prior to use and that teriparatide...