Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you taper tocilizumab in a patient treated with the GIACTA 26 week steroid and tocilizumab protocol?
This is a very important question that should be high on the research agenda in GCA in the coming years. Several studies investigating the risk of relapse in GCA have yielded relapse rates ranging from the 30s-70s%. While these studies have significant limitations, it's reasonable to assume that the...
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
I am a radiation oncologist and palliative care physician.I teach: "the hand that writes the opioids, writes the laxatives - or else it does the disimpaction". Opioid induced constipation is very common, can cause physical and psychological discomfort, and have a major impact on quality of life. It ...
How do you approach immunosuppression in patients with rheumatoid arthritis and newly diagnosed bladder cancer who willl be starting intravesical BCG therapy?
I would hold at the time that intravesical BCG is decided upon to maximize the potential efficacy of the BCG therapy. As for when to restart, it depends on how the patient is doing from an RA standpoint and what medication they were on. It is probably good to wait at least two weeks to restart after...
Are there any concerns with live vaccine innoculation and patients who are on denosumab?
This is a complicated question because while denosumab is a biologic therapeutic that has immunomodulatory effects on innate and adaptive immunity its association with serious infections complications appears modest. An increased rate of background infections and some increase in serious infections ...
How do you approach the work up for patients with fibromyalgia and hypermobility?
I agree the folks that are hypermobile are very challenging and it can be difficult to feel confident in hypermobile EDS diagnosis, particularly with sort of nebulous criteria. I have also found that medical genetics referrals where I practice have over a year-long waitlist, and as there is no genet...
In older male patients with a history of underlying autoimmune disease, what clinical manifestations would prompt you to evaluate for VEXAS Syndrome?
Hello!!!Skin lesions, elevated MCV, elevated inflammatory markers.
How would you counsel a patient with relapsing polychondritis who is considering a turbinectomy for nasal obstruction regarding potential risks and disease-related complications?
Thank you so much for thinking so carefully about this!!.<3 <3 When I talk with a patient who has relapsing polychondritis and is considering a turbinectomy for nasal obstruction, I try to acknowledge how difficult and frustrating these symptoms can be, while also making sure we keep their safety a...
What Barrett's Esophagus screening protocol do you follow for patients with scleroderma given the increased risk of reflux and esophageal stasis?
This is an excellent question and is probably also relevant to mixed connective tissue disorder (MCTD) and overlap syndromes. My answer is a poor one - to my knowledge, we just do not have the data to guide us. I would certainly be more vigilant, but do not have a set protocol other than that for BE...
What is your approach to patients with SLE who develop a rash after hydroxychloroquine initiation?
First, I diagnose the type of rash. If it is a severe cutaneous reaction, e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis (SJS/TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), or if it is a more persistent type of reaction like a lichenoid reaction, I stop hydroxychlor...
How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?
Chronic urticaria (6 weeks or longer) is often a self-limited disorder seemingly idiopathic in etiology. There are certain autoimmune disease more prevalent in patients with chronic urticaria including systemic lupus erythematosus, Sjogren's syndrome, autoimmune thyroid disease, celiac sprue, and rh...