Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there specific conventional DMARDs and/or biologics that are contraindicated in patients with alpha-gal allergy?
Here is a Q&A from AAAAI (American Academy of Allergy, Asthma and Immunology) addressing this question for etanercept and other monoclonal antibodies that are manufactured in cell lines that glycosylate with alpha-gal. The author concludes, "The risk is not zero, but likely very low".
What are some practical tips for eliciting an accurate history of Raynaud's phenomenon in patients being assessed for CTD?
I use this approach. I first ask patients if they feel generally sensitive to the cold. All patients with Raynaud's should respond yes to this, but this is not specific, as there are many cold-sensitive patients who don't have Raynaud's. I will then ask if their fingers turn any colors in response t...
How do you approach a child with recurrent parotitis who has had negative serum testing for Sjogren's and IgG4 related disease?
Minor salivary gland biopsy is pretty random and subjective; finding >50 lymphocytes per set field is not that specific/helpful. I would think a parotid gland biopsy and extensive work-up (TB, HIV, sarcoid, lymphoma, etc.) is in order.
How frequently do you monitor CT scans, PFTs, and TTEs in patients with ILA or mild ILD?
Typically, I want my patients with ILD to be seen in clinic every 3-4 months, but of course, that depends a great deal on individual circumstances (e.g., disease severity, what we're doing for their disease, etc.). My typical approach is to have my patients perform spiro, DLCO, and 6MWT Q 3-4 months...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
How do you approach initial steroid dosing in patients with eosinophilic fasciitis?
I usually start with a high dose at 60 mg daily for a few weeks, then add DMARDs like MTX.
Do you find trabecular bone score (TBS) useful in patients with a history of ankylosing spondylitis when screening for vertebral fracture risk?
Yes, the ankylosing spondylitis population is a group that could benefit from the evaluation of TBS. DXA-based spine bone mineral density is artificially elevated in the setting of ankylosing spondylitis (due to osteosclerotic artifact from underlying disease), and therefore, spine bone density is a...
Would you consider using LDRT for joint pain/arthritis caused by aromatase inhibitors as a means to keep patients on therapy?
I would try this. I think there is an inflammatory component to this, and the subjective complaints appear to mimic OA. However, I do think this would be a wonderful group of patients to try this on. They are probably already comfortable with radiation, the achiness/discomfort from ET is real and we...
What is the preferred osteoporosis therapy after completing teriparatide in a young woman planning pregnancy within the next year?
It would be helpful to know the T-scores of the spine and femoral neck. I also like to have the bone remodeling markers. My recommendation would be adequate calcium intake of 1000 mg daily, preferably from diet, and 4000 IUs of vitamin D daily, not only to help preserve bone health, but vitamin D al...
How would you approach management of a young woman referred for isolated anterior uveitis (now resolved), in the absence of systemic manifestations or end-organ involvement, but with serologies notable for strongly positive PR3 (negative c-ANCA)?
This is a challenging case. While up to 50% of anterior uveitis are idiopathic, and uveitis is relatively uncommon in GPA (<5-10%, episcleritis and scleritis are the most common ocular manifestations. The PR3 antibody is quite specific. Therefore, I would have a high index of suspicion that the uvei...