Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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.
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 ...
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...
Would you check ANCA titers in a patient with a history of PR-3-ANCA glomerulonephritis in remission and a stable creatinine but with recurrent microscopic hematuria?
Not sure there is an easy answer to this. A patient in remission should not get a recurrence of glomerular hematuria unless the disease is active. A new onset glomerular hematuria would certainly make me worried about a relapse, some of which may be subtle, indicating "grumbling disease". The data o...
Would you recommend waiting for a low Vitamin D level to correct to goal prior to giving a scheduled Prolia injection when transitioning a patient from Zolendronic acid to Prolia therapy for worsening osteoporosis?
When ZA is in its early days patients had to have a D level of 15ng/ml. To be on the safe side most of us want a 25 ng/ml level which is easy to obtain.
What is your experience with using anabolic therapy for treatment of osteoporosis in patients with EtOH cirrhosis and is one agent preferred over another (PTH analogue vs Evenity)?
The approach that has been recommended may be reasonable. It is important to recognize that a bone density score consistent with osteoporosis does not necessarily mean that the patient has osteoporosis i.e. loss of mineral and matrix. Osteomalacia, a mineralization defect of the collagen elastin mat...