Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach management of a patient with multiple lung nodules and low titer +CCP but no active joint symptoms suggestive of RA?
In the absence of other clinical symptomatology, I would favor close observation and follow-up in this case as there is no established diagnosis and repeat CT, PFT’s in 3 to 6 months. Details of initial evaluation should include PET-CT to exclude malignancy but also to investigate other organ system...
How would you manage a patient with discordant TBS adjusted T-score and traditional T-score?
The ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis) and IOF (International Osteoporosis Foundation) recommend the use of TBS-adjusted T-scores to help guide osteoporosis treatment decisions. However, this recommendation is based on a single research study and therefore may...
Would you consider utilizing transdermal estrogen for HRT to treat severe hot flashes in a patient with SLE and a history of thrombosis x2 and positive lupus anticoagulant, but negative aCL/B2GP1 abs?
Given the prothrombotic effects of estrogen, they are generally avoided in patients with prior thrombosis and hypercoagulable states. Therefore, in a patient with SLE, secondary anti-phospholipid syndrome, as a single positive aPL with a positive lupus anticoagulant, and prior thrombotic event, the ...
Are you comfortable using belimumab in patients with a history of significant depression?
YES! (look at the numbers below)... edited as I accidentally initially said no. There was numerically increased suicidality and depression in the phase 3 clinical trials of IV belimumab (BLISS-52 and BLISS-76). Unfortunately, there were two completed suicides. Two things occurred due to this: Subseq...
Would you consider prescribing a JAK inhibitor for a patient with a history of DVT who is on chronic anticoagulation, or would the thrombotic risk deter you?
There is no definitive answer here except to say that most rheumatologists would likely explore and employ all other available options prior to selecting the higher-risk one in this type of patient. But, ultimately, if all other options were exhausted and unsuccessful, you still have a patient with ...
What is your approach to treatment of macrolide-sensitive localized bone/joint MAC disease?
Agree with the above answers. Obviously, no strong clinical studies on duration and outcomes. At NJH, we typically recommend: Aggressive debridement/resection, Treat with appropriate antimicrobial therapy (in macrolide-S MAC, then AZM/EMB/Rifamycin +/- IV AMK) for a minimum of 6 months total, but a...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...
How do you counsel patients with RA stable on csDMARDs on whether to attempt tapering or not?
It is important to recognize that this counseling is highly individualized and that factors such as risks of medication toxicity, age, comorbidities and disease severity all play a part. However, several studies have demonstrated a significantly increased risk of RA flares and radiographic progressi...
In a patient with Class IV lupus nephritis and cardiomyopathy who has received cyclophosphamide, how do you approach the use of biologics such as belimumab or voclosporin in the setting of ongoing proteinuria?
Voclosporin and belimumab have both been shown to have efficacy in the treatment of lupus nephritis, and are exciting options to consider, as also recommended in the ACR guidelines. One of the key questions for ongoing proteinuria is the degree of active disease vs chronicity, and the role of a (rep...
How do you interpret DXA results in cases where there is discordance between normal hip and spine BMD with abnormal one-third radius BMD?
This is an interesting question. To my knowledge, there are no fracture prediction models based only on forearm bone density values so my response is my opinion and not evidence-based. Firstly, we always rule out hyperparathyroidism when there is forearm bone discordance compared to spine and hips s...