Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there any new treatments for erosive osteoarthritis of the hands?
Unfortunately, the short answer is “no.” Hand OA, in general, is one of the more refractory forms of OA, and erosive OA is even more so. A variety of theoretically useful approaches have been tried, based on our understanding of inflammatory arthritis in general. However, recent placebo-controlled t...
Given the risk of hypocalcemia in dialysis dependent patients treated with denosumab, what is the best method of treatment for osteoporosis for these patients, and should we be transitioning to a different agent?
Hypocalcemia can be prevented by providing adequate calcium, 1,200-1,500 mg in divided doses daily, and adequate calcitriol to absorb it. Good results also occur when the patient has tertiary hyperparathyroidism with hypercalcemia.
What is your preferred management approach for scleroderma renal crisis in a patient with a history of anaphylaxis to ACE inhibitors?
The important thing is to lower the BP regardless of the how. ACE I were the first medication to show survival benefit in patients with scleroderma renal crisis so they have become the treatment mainstay. Time is kidney so the best treatment is to lower the BP with whatever BP lowering medication yo...
Do you routinely pursue cardiac evaluation in children presenting with post-streptococcal reactive arthritis given the diagnostic overlap with acute rheumatic fever?
Yes.
Do you continue methotrexate while starting TNFi therapy in patients with refractory pulmonary sarcoidosis?
No clear data to do this in an EBM fashion in my opinion. I keep the baseline anti-inflammatory agents the same for the initial two doses of infliximab and once they are on regular dosing, I decrease the other agent/s. After steady-state, I would still keep a low dose of prednisone (2.5 or 5 mg dail...
Have you seen microscopic polyangiitis associated with temporal artery involvement?
Temporal artery involvement or large vessel involvement in general can be seen in the anca vasculitides, though it is not common. A published series (Kaymakci et al., PMID 37672018) reported 17 patients with TA involvement in AAV patients. Another study of 101 patients with AAV reported the prevalen...
What is your preferred initial treatment strategy for patient with new diagnosis of seropositive RA who has end-stage renal disease?
My initial response is to make sure that the diagnosis of RA is correct. Onset of arthritis in a patient with end-stage renal disease could be from other causes maybe even related to the renal disease itself such as gout or CPPD. If this is truly RA, then the safest approach for initial management w...
What are your thoughts on using abatacept for RA-associated ILD in a patient undergoing treatment for CLL with zanubrutinib, and how would you assess the potential increased risk of infection in this context?
Zanubrutinib is an inhibitor of Bruton tyrosine kinase which is part of an important signaling pathway for B cells. BTK inhibition prevents B cell activation, proliferation, and survival. It is useful for B cell malignancies such as CLL.I have two concerns about using abatacept and zanubrutinib toge...
Do you prefer allopurinol or febuxostat for patients with chronic kidney disease who are receiving treatment for asymptomatic hyperuricemia?
Allopurinol. For my Asian and sometimes African American patients, I consider HLA testing to make sure they are not at risk for allopurinol hypersensitivity. In which case, I will prescribe febuxostat. Most often, I find the insurance will not even cover febuxostat unless I have tried allopurinol fi...
How do you approach new-onset idiopathic intracranial hypertension (IIH) with someone who has history of systemic lupus erythematosus?
Since there is not a clinical recurrence of lupus, let's assume the disease is quiescent. The patient may have a clotting tendency so extra care should be taken in MRV interpretation. Does the MRV show the smooth-walled flow-related stenoses of intracranial hypertension or is it more consistent with...