Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider starting short-term metformin in an otherwise healthy patient who is beginning high-dose glucocorticoids to prevent glucocorticoid-induced insulin resistance?
Sustained use of glucocorticoid therapy is well recognized for causing hyperglycemia in patients without known dysglycemia. Rates of 15-25% have been reported depending on the clinical situations and the doses and duration of steroid use. A safe, effective, and cost-friendly approach to prevent this...
Do you offer LDRT for psoriatic arthritis, rheumatoid arthritis, or polymyalgia rheumatica or fibromyalgia?
I have treated for RA and PA. I have not had any referrals for PMR or fibromyalgia. I have not considered for fibromyalgia, as I don't understand the condition well. For RA/PA, in many cases, they have not had any relief from medications, therapy, NSAIDs, and relying on opioids and other, at times, ...
Is there any benefit to the use of low dose radiation in patients with osteoarthritis who have already undergone joint replacement?
I've treated a lot of patients with LDRT for OA, but not many with joint replacements. The ones that still have pain after a joint replacement - I have told them that mechanistically it does not make a whole lot of sense to treat - I don't imagine it will have that same anti-inflammatory effect, as ...
How do you manage injection site reactions in patients on subcutaneous biologics such as TNF inhibitors?
Injection site reactions are not infrequent, though the majority are self-limited and do not result in discontinuation of the drug. For those uncommon few individuals whose skin lesions are more prominent and symptoms (such as pain and itch) are aggravating, I first review that they are properly sel...
What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?
Nonbacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks endocarditis, is a form of endocarditis characterized by the presence of sterile vegetations on cardiac valves. It is most commonly associated with systemic autoimmune conditions, notably systemic lupus erythematosus (SLE) and a...
When is it appropriate to refer a systemic sclerosis patient for bone marrow transplant evaluation?
I consider patients for referral who have early diffuse disease who have continued to progress despite standard of care therapies. I think some would argue that this may also be appropriate for early patients as first line therapy if they have high risk features for progression, but I typically will...
Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?
Liver elastography is a useful tool to use when assessing the potential hepatotoxicity of various drug therapies. Traditionally, methotrexate accounted for nearly all the hepatotoxicity issues that we faced; however, we can add many other drugs to that list. Virtually, every immune suppressive drug ...
What treatment regimen would you recommend for a patient with biopsy-proven giant cell arteritis and diffuse cutaneous systemic sclerosis?
This is a challenging situation in which you must weigh the well-known high risk of irreversible blindness in untreated GCA with the known increased risk (but not necessarily 100% risk) of scleroderma renal crisis with steroid exposure >=15mg (Steen and Medsger, PMID 9751093). It is important to und...
How long are cholinergic agonists such as pilocarpine required to be held before doing tear assessments (ocular scoring and Schirmer’s) and sialography/salivary collection?
Discussed this with ocular and oral colleagues in the Berkeley Sjogren's Clinic. Neither request patients be off secretagogues before testing. If the testing is normal, and there is a reason to retest, they will ask the patient to hold the medication for 12-24 hours. Ocular expert did not see much e...
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...