Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
Would you have concerns using azathioprine in NXP-2 or TIF-1 gamma positive dermatomyositis patients due to higher risk of malignancy?
No studies have examined the effect of long-term azathioprine and the risk of malignancy in myositis. However, data from other autoimmune diseases (like lupus, myasthenia gravis, multiple sclerosis) have been negative in most cases (except perhaps for rheumatoid arthritis), and distinct from what is...
Would you have any concerns about starting an anti-TNF in RF and anti-CCP positive RA patients who also have high titer ANA?
No, I would not have any concerns. A patient with seropositive RA who demonstrates a positive ANA remains a patient with RA, not someone with an overlap connective tissue disease syndrome. Since a positive ANA can be seen in a sizable percentage of healthy people and among those treated with TNFi dr...
How do you evaluate and manage brain fog in patients with underlying rheumatic disease?
For Brain fog – Most important this is I stress to patients – there are likely MULTIPLE different things contributing to brain fog, so there are MULTIPLE different things we are going to have to work on to improve it. Active inflammation might be contributing, but there is likely several other facto...
Would you consider the use of romosozumab in men who have failed therapy with teriparatide and sustained multiple vertebral fractures?
Yes, I would consider Romosozumab for the male patient. I would check his cardiovascular status due to concern of the possible increased risk for a cardiovascular event on the medication, which could be a contraindication. However, before initiating therapy, it would be helpful to know some of the s...
Do you cycle through topical steroids in patients with CHE, and should the approval of delgocitinib change our approach on this?
In practice, I do often cycle topical steroids in chronic hand eczema to balance access, efficacy, and safety. Patients are often referred from primary care already having tried multiple topical steroids. Potent topical steroids can help with acute control, but long-term use is problematic. The avai...
Are there certain clinical features that help you choose between benralizumab and mepolizumab for EGPA in clinical practice?
Given, as noted above, no significant clinical differences between benralizumab and mepolizumab, assuming there are no specific insurance differences between the two, I preferentially prescribe benralizumab because of the 8-week dosing frequency after the first three 4-week loading doses. For a few ...
In patients with SLE and coexisting knee osteoarthritis, how useful is musculoskeletal ultrasound particularly power Doppler in distinguishing an SLE inflammatory arthritis flare from an OA flare when serologies and inflammatory markers may not be helpful?
Unfortunately you are correct. Ultrasound alone is not able to distinguish between an effusion or synovitis due to the patient's OA or SLE. You would have to assess clinically for other evidence of an SLE exacerbation, and/or aspirate and analyze the fluid (which may be easier using ultrasound guida...
What would be the minimum duration of IL-1 therapy you would recommend for chronic pericarditis?
There is no great data. In my experience, it depends on the reason for IL-1 initiation, the severity of cMRI findings, and how chronic the pericarditis was prior to initiation.. If this is used as a steroid-sparing strategy or steroid weaning, probably 1-2 years minimum. In Rhapsody, the majority fl...
When do you obtain nerve biopsy to evaluate for vasculitic neuropathy in patients with distal symmetric polyneuropathies?
Excellent question. Vasculitic neuropathies can occur as part of systemic or isolated peripheral nerve vasculitis (PNSV). While the majority of PNSV presents as mononeuropathy multiplex (>50%), it is well known that the rest of the patients present either with confluent mononeuropathies (which began...