Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to discordant dsDNA testing, such as positivity to dsDNA by crithidia but negativity to dsDNA by other modalities?
What a great question with many facets. The information I provide is meant to be very practical. These answers are from the viewpoint of a rheumatologist and not an immunologist. I discussed this subject with Dr. Debra Zack, a rheumatologist/immunologist who is an expert with anti-dsDNA, and I had t...
Do you assess baseline salivary gland function before starting treatment in patients with Sjogren's syndrome?
No. Visual assessment of salivary pool and oral mucosa is routinely done. In the initial consultation and management plan, most always, referral to Sjogren's Oral Medicine Specialist is made where whole salivary flow is measured, usually by Unstimulated Whole Salivary Flow Rate (abnormal, less than/...
When considering the use of DOACs in APLS, does the number of positive APLS antibodies influence your decision?
The number of antibodies is an important consideration.On the one end of the spectrum, I would not recommend any DOACs in a triple positive APLS (especially with arterial thrombosis). Having said that, I would not change treatment in a triple positive APLS patient if they were started on DOACs in th...
What is the most impactful career advice you have received from a colleague or mentor?
Whenever you take care of a patient, treat that patient like they are the most important person in the world in that moment, and let them know it by your words and actions.
How do you approach prescribing analgesics for osteoarthritis related pain in patients with comorbidities, particularly given new evidence that even acetaminophen is associated with increased risk of GI complications (bleeding, peptic ulcer disease), heart failure and CKD?
Acetaminophen is still preferred, but at 3,000 mg or less per day. The next consideration is a COX-2 specific inhibitor, such as celebrex. Narcotics and steroids play no role in management of osteoarthritis.
Can lupus anticoagulant be positive despite a normal aPTT?
aPTT is one of the assays that may be abnormal in the presence of lupus anticoagulant, but not always. Usually, when screening for lupus anticoagulant, there will be a "special" aPTT assay used that is a bit more sensitive to detect lupus anticoagulant. There are several different aPTT-based assays ...
Should HCQ be continued in an asymptomatic SLE patient who has received renal transplant?
As far as I know there is not a definitive answer to this question due to a lack of clinical trials. My approach is to continue it at a dose adjusted for renal failure. My thought process is that both lupus and chronic renal failure increase the risk of cardiovascular events significantly. Plaquenil...
Do you prefer using losartan in your patients with hypertension and gout due to its uricosuric effects?
I do find losartan helpful. It is especially helpful asking a PCP to change HCTZ to losartan. Though the losartan's urate-lowering effect is a small amount, I combine this with dietary changes (especially greatly limiting the intake of foods high in fructose) and eating purines in moderation, and e...
Do you still consider the use of pegloticase in someone with substantial tophaceous burden despite optimal uric acid levels?
If a patient has a significant burden of tophaceous deposits causing functional impairment despite serum uric acid control achieved through oral uric acid lowering therapy (ULT), I strongly recommend considering a course of enzymatic therapy with pegloticase. Terms such as “treatment failure gout” o...
What is your approach to dental prophylaxis for patients on biologics?
My approach has been to not recommend antibiotics prior to routine dental care for patients on biologic therapy. I'm not aware of any compelling evidence or guidelines supporting preventive antibiotic treatment for such patients. Of course, there may be exceptions to this. Antibiotic prophylaxis mig...