Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you treat tophaceous gout after a course of pegloticase infusions if the patient has contraindications or intolerance to allopurinol, febuxostat, and probenecid?
Difficult question. I think there are a number of issues to address. What is a "course of pegloticase?" What are the patient's contraindications to treatment? How did intolerance to prior oral uric acid-lowering therapies manifest Was pegltoicase started because of "unresponsiveness to oral ULT" an...
Do you routinely supplement folic acid in patients with rheumatoid arthritis who are taking sulfasalazine?
No, I do not routinely use folic acid supplementation in patients with RA on sulfasalazine. It is recommended to supplement FA for those taking sulfasalazine in pregnancy.CC @Dr. First Last if any additional comments on this!
Would you perform screening for pulmonary hypertension in a patient who has biopsy-proven Sjogren's but has a centromere antibody?
Generally, the risk of pulmonary hypertension in Sjogren's is low - about 2% in a recent study using RHC for diagnosis (Coppi et al., PMID 40058609). There have been no studies linking Raynaud's to pulmonary hypertension risk in Sjogren's, although this is true in systemic sclerosis. So the real que...
What guides your choice between prophylactic, intermediate, and full therapeutic dosing of enoxaparin in a woman with APLS and prior fetal loss with no hx of thromboembolic disease?
First, it is essential to confirm that patients meet criteria for obstetric antiphospholipid antibody syndrome (OAPS), based on the 2023 ACR/EULAR classification criteria. This includes persistently positive laboratory criteria (confirmed on repeat testing >12 weeks apart), plus otherwise unexplaine...
How do you approach management of mucinous cysts associated with hand osteoarthritis?
These cysts develop dorsally between the distal interphalangeal (DIP) joint and the proximal nail fold, are filled with synovial fluid associated with inflammation and damage to the joint capsule. Fluid escapes and accumulates, communicating with the adjacent joint. While they are often asymptomatic...
What additional workup would you perform to evaluate a new onset of spontaneous hemarthrosis?
The workup that you've outlined is essentially complete. Would rule out any possible medication/supplement effects, Would consider the possibility of a vascular fragility syndrome (EDS) or other connective tissue disease, Would rule out vitamin C deficiency, If there is other bleeding that clinical...
How long do you treat retroperitoneal fibrosis with immunosuppression?
I normally treat for 9 months to a year depending on response. I have found PET CT useful in determining if there is active ongoing inflammation.
For ICI arthritis, how soon do you start DMARDs?
Great question! This is complicated- is it one joint? Inject with steroids! Are there many joints? Is it gout-based, spondyloarthropathy, or more like seronegative RA or PMR-like?Also, where are they in the cancer space? In surveillance but high risk, what type of cancer, etc, etcI start this way: 2...
Do GLP-1 agonists have measurable anti-inflammatory effects in diseases like RA or spondyloarthropathies beyond weight loss?
There is currently no evidence of efficacy in chronic inflammatory arthritis. Due to their mechanism of action, we can hope that they will be effective because of their anti-inflammatory and immunomodulatory properties, which have been well demonstrated in numerous experimental models. But only rand...
How do you approach adding colchicine to a patient who is on a stable statin regimen?
This is a good question and a tough situation, since the drug-drug interaction here can be as subtle as myalgias but as severe as rhabdomyolysis (rare but happens). If you can avoid long-term colchicine in this situation, it is always best. These situations (hypercholesterolemia and crystal arthropa...