Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you manage episodes of Raynaud's that are frequent and bothersome in the winter months?
If Calcium channel blockers (Nifedipine extended release, Amlodipine) have been trialed already, and non-pharmacological management [including avoiding cold exposure, stress, and certain vasoconstrictive medications (e.g., beta-blockers, nasal decongestants, amphetamines, migraine drugs)] has been m...
How should rheumatologists address the impact on patients who are initially diagnosed with SLE based on positive ANA, but later reclassified as having UCTD?
I experience this question a bit differently. Patients who are told they have a diagnosis are frequently living in a certain mindset with a certain expectation and possibly even a fear of the alteration of their life. The patient with a diagnosis trusted a doctor to give them sound and honest advice...
What is the recommended timing for starting denosumab after completing zoledronic acid?
6 months
How do you handle hypogammaglobulinemia detected in patients prior to maintenance rituximab infusion?
That is a good question. Adding on to Dr. @Dr. First Last's response, rituximab has been shown to cause hypogammaglobulinemia that can persist or worsen with ongoing therapy. In a study published by Barmettler and colleagues, 133 patients out of a cohort of 8633 patients had serum IgG levels checked...
How would you manage active severe psoriasis in a patient planning pregnancy, who also has psoriatic arthritis with well-controlled joint symptoms on certolizumab pegol (anti-TNF therapy)?
If the psoriasis was sufficiently limited in area that topicals were a practical solution, I'd first try to assure that the prescribed topical steroids were being used well. Poor adherence is a common issue with topical treatment. Phototherapy might be my next choice. I feel comfortable prescribing ...
Do you check IgA levels before starting IVIG for other autoimmune conditions?
Whereas it is not mandatory to check IgA levels before starting IVIG, it is prudent to do so in non-urgent situations since the patients with IgA deficiency, especially those who have developed anti-IgA antibodies, are at an increased risk of severe hypersensitivity or anaphylactic reactions from IV...
Are there any successful disease modifying therapy for diffuse idiopathic skeletal hyperostosis (DISH)?
Therapy for DISH is largely supportive: PT, NSAIDs/pain relievers, and control of contributing metabolic conditions, nutrition, exercise, and lifestyle changes; when necessary surgical interventions such as surgical resection of osteophytes and spinal fusion are required.Clinical research in DISH is...
How do you approach DMARD therapy in a patient with lupus and recurrent pericarditis?
Both asymptomatic pericardial effusions and symptomatic pericarditis are common in systemic lupus erythematosus (SLE) patients. I will limit my answer to symptomatic pericarditis per the question.The first thing to be sure of is that the symptoms are truly due to pericarditis. The full differential ...
Does treatment with hydroxychloroquine increase the risk of hypertension or exacerbate pre-existing hypertension?
The answer to this question is that it depends. A number of studies have reported improvement of hypertension with hydroxychloroquine. A large population study suggested there is a subpopulation of patients that may experience an increase in blood pressure on hydroxychloroquine, primarily women over...
Do you recommend vasodilators in patients with Raynaud's who have capillary drop out but are otherwise not bothered enough by their symptoms to want to pursue systemic treatment?
I typically do not unless they have had ischemic events in the past (like pitting or ulcers). Unfortunately, we do not have good longitudinal data to support the idea that prophylactically treating patients with vasodilators when they are otherwise minimally symptomatic will have a preventative role...