Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?
This is an important concept because anyone using tocilizumab will eventually wrestle with this question. The question, though, does not tell you whether this is the first time a practitioner sees the liver enzyme elevation, or how high the liver enzymes rose. Since everyone should have had a lipid ...
How do you approach managing nausea and GI side effects when initiating methotrexate?
There are several strategies to minimize nausea and gastrointestinal symptoms with the use of methotrexate. The medication can be taken with food, just not with caffeine. The dose can be split throughout the day it is taken such as half the dose in the morning and the other half in the evening. The ...
Is it necessary to prescribe a steroid taper after two weeks of high-dose prednisone (60 mg daily)?
Interesting question. Not being an endocrinologist, I don't have the expertise to advise but the reference below makes the statement that even short-term steroids can be an issue. I suspect that if you have to stop abruptly from 60 mg daily for 2 weeks, it would probably be fine in most instances bu...
How do you approach the frequency of DEXA scan monitoring for older adults on bisphosphonate therapy during the course of therapy?
Depends who you read. ACP: Recommendation 4: ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women. (Grade: weak recommendation; low-quality evidence) [1] Monitoring wasn't addressed in the 2023 update. ACR: For adults continuing...
Would you proceed with renal transplant in a patient with lupus nephritis who has progressed to ESRD and is clinically stable, but has persistently elevated dsDNA and low complements despite appropriate doses of hydroxychloroquine and mycophenolate?
Short answer: Yes—if the patient’s clinical lupus is quiescent for at least 6 months, it is reasonable to proceed with kidney transplantation even in the presence of persistent serologic activity (e.g., low complement, elevated anti-dsDNA).Why this matters: Transplant > Dialysis: Patients with LN-ES...
In patients with RA on methotrexate and a TNF inhibitor who develop PJP pneumonia, how long do you hold immunosuppression before restarting therapy?
I would typically hold immunosuppression until the patient has completed therapy unless they had significant respiratory failure, in which case I would await full recovery. The patient should be placed on appropriate PJP prophylaxis prior to resuming therapy.
In patients with an acute gout flare who have stage 3–4 CKD or are on anticoagulation, what is your preferred first-line treatment?
This is a challenge. Intra-articular steroids may be the best option. Colchicine is an extremely complicated issue. A single dose of colchicine at 0.3 or 0.15 mg might be considered. Systemic steroids probably should be avoided because they reduce resistance to infection in an already compromised in...
When should bone biopsy be considered to guide management in patients in whom you're differentiating osteoporosis and renal osteodystrophy?
This is a major issue in patients with advanced CKD. Definitive RCT treatment trials for osteoporosis had an inclusion criteria of a normal PTH and an exclusion criteria of elevated creatinine greater than 1.1 to 1.5 (depending on the study). Therefore, in patients with CKD 3 and more severe CKD, AN...
What is the next best osteoporosis treatment option for patients who completed 2 years of teriparatide, but has contraindication to bisphosphosnate therapy (e.g. history of atypical femur fracture)?
I have successfully treated several patients with bisphosphonate-induced subtrochanteric femoral fractures with Forteo. However, before initiating another antiresorptive therapy, I first want to be sure that the Forteo at the desired effect on bone remodeling by increasing both bone formation and bo...
In which patients with CHE will you prioritize early use of delgocitinib?
I think about delgocitinib early in patients with recurrent flares, lack of efficacy or adverse events with steroids, or those with a significant impact on daily function or work ability. I would consider skipping steroids entirely, but typically, when I see patients, they have already tried topical...