Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there any indication for IVIG in immunocompromised patients with only decreased IgM and/or IgA levels?
Nope. IVIG preparations contain IgG not IgA or IgM. Low serum IgA may or may not be associated with low IgA levels in mucosal surfaces leading to a risk of local infections. Low levels of one or both may be asymptomatic but in the right setting might suggest a need for evaluation of plasma cell dysc...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Do you use naltrexone in your patients with fibromyalgia?
I do not use low-dose naltrexone as a first-line agent for patients with fibromyalgia. Well-designed RCTs (Due Bruun et al., PMID 38258677; Bested et al., PMID 38226027) have not shown significant improvements in pain or other outcomes in the overall population of patients with fibromyalgia. That sa...
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...
What is your approach to counseling patients on the safety and side-effect profile of a biosimilar compared to its reference biologic?
Relevant question as insurance companies may require a biosimilar over the reference biologic. According to the FDA, the spin-off (my term) must be "highly similar" to the original in both efficacy and safety. Approval is based on review of clinical trial data. As for my approach: until proven other...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
Do you prioritize aerobic exercise over pharmacotherapy as the first active intervention in a patient with newly diagnosed fibromyalgia who has no prior treatment?
I use both in parallel as first-line agents. No one will improve if they're not moving (I use the word "movement" or "activity," rather than "exercise," as this could sound excessive to some folks). I only avoid pharmacotherapy if the pt. feels strongly against taking medications, but most people ar...
What’s your drug of choice for patients with stable antisynthetase NSIP-ILD and overlap RA (CCP+) with significant polyarthritis as main manifestation?
Rituximab