Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When discontinuing Denosumab after more than 2-3 years of therapy, when do you recommend giving the first dose of zoledronic acid?
My practice has been that after 2-3 years of denosumab, I wait 6 months and then start zoledronic acid.
How do you think about using Ropeginterferon Alfa 2B for polycythemia vera in patients with active autoimmune disease?
Great question. In general, I avoid interferons in patients who have an autoimmune disease. In the PROUD-PV/CONTI-PV study, a medical history of autoimmune disease was an exclusion criterion. There have been reported cases of interferon-induced autoimmune disease, most commonly autoimmune thyroiditi...
Do you have to extend treatment for acute Lyme disease if a patient is on high dose steroids for another indication?
I am unaware of any evidence to support longer-term therapy in such a setting. I am quite sure no such study has ever been done. Standard therapy for early Lyme disease is 10 days of appropriate antibiotics. Extending to 20 days would likely do no harm to the patient, but may not be necessary, and t...
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
When evaluating a patient with IgG4-related disease, are there particular exposures or risk factors you routinely ask about during the history to help identify potential contributors?
While there are no well-established environmental or occupational risk factors but taking a thoughtful exposure history can provide valuable information about the phenotype of the disease and help exclude mimics. I routinely ask about the history of allergic or atopic conditions such as asthma, alle...
How do you approach perioperative management of anabolic therapies such as romosozumab and PTH analogues in patients undergoing joint replacement?
Although there is no good human data, there is some pre-clinical data that shows increased screw purchase in the setting of tptd use. It makes good common sense that an anabolic (both PTH types and romosozumab) would likely increase the purchase of an implant. In addition, if the patient had signifi...
What is your recommended rheumatic disease evaluation for a pediatric patient presenting with interstitial keratitis and a negative infectious disease workup (e.g., HSV, syphilis, Lyme)?
We work very closely with our Ophthalmology colleagues when coming up with treatment plans for these patients, as we cannot see what is happening in the eyes and rely on them to assess disease activity! The pediatric rheumatologist's role in these ocular diseases is to screen for underlying systemic...
Is elevated bone-specific alkaline phosphatase an absolute contraindication to teriparatide?
The original label for Forteo gave a warning against using teriparatide in patients with an “unexplained alkaline phosphatase”. This was clearly meant to avoid the use of teriparatide in individuals who may have Paget’s Disease of the bone. Since Paget’s disease has an independent increased risk for...
How would you approach a male in his 60s with bilateral optic perineuritis/neuritis on MRI, steroid-responsive bilateral jaw pain, normal ESR/CRP, negative temporal artery biopsy, and elevated IgG4?
This is a challenging case with a number of atypical features. When approaching such a scenario, I try to categorize the presenting clinical features by their specificity. In this case, optic perineuritis has a broad differential, including MOG, MS, sarcoidosis, SLE, systemic vasculitis, and infecti...
Do you recommend initiating zoledronic acid for osteoporosis at the time of hospitalization for a fracture?
I did not institute bisphosphonate therapy during hospitalization for a fracture. It would have been helpful to have known bone remodeling markers if the patient had been followed for osteoporosis. It is reasonable to institute antiresorptive therapy in patients with high bone turnover. However, I d...