Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you manage a patient with Takayasu arteritis controlled on TNFi who develops erythema nodosum that is only partially responsive to NSAIDs?
Erythema nodosum and pyoderma gangrenosum (as well as erythema induratum) are well recognized as cutaneous manifestations of TAK. Unfortunately, we do not know how often cutaneous and the vascular disease are decoupled from each other due to a lack of available data. Most case series document associ...
Would you try combination ketorolac and cortisone injections in a patient with severe knee OA who refuses surgery and had partial responses to injections of cortisone and ketorolac separately?
Clinical use of intraarticular injection of ketorolac has gained some popularity, especially in the orthopedic community, although the I.A. route is not an approved indication by the FDA. As such, its use is off-label, which may make reimbursement difficult in the U.S. Nonetheless, there have been s...
How would you approach the workup and management of isolated inflammatory subglottic stenosis in a young previously healthy patient that is steroid responsive with a completely negative serologic autoimmune workup?
This is a relatively unusual situation in that idiopathic subglottic stenosis is typically not managed with systemic immunosuppression. The typical therapies are endoscopic and include dilatation (+/- intralesional corticosteroids), endoscopic resection, and cricotracheal resection. A recent large t...
Would you consider PTH analogue in a patient with mildly elevated PTH?
This is a complicated question because there is not any substantial literature. Almost all clinical trials with teriparatide and abaloparatide excluded patients with elevated PTH levels. However, there is considerable anecdotal experience. I have surveyed many colleagues with considerable experience...
How do you approach a patient with elevated bone specific ALP (>2X the normal limit), but no other evidence of Paget's disease?
There are other causes of elevated bone alkaline phosphatase e.g. osteomalacia. Check blood calcium, magnesium and phosphate, PTH and 25-OH-vitamin D. If PTH is elevated and no CKD, check 24-hour urinary calcium and creatinine.
How often should lupus anticoagulant be checked in patients with SLE if prior was negative or if prior was positive?
The key question when considering retesting for any laboratory test, including antiphospholipid antibodies (aPL), is: How would a positive or negative result change the patient's management or prognosis? This question helps guide the decision-making process by focusing on the potential clinical impl...
How do you approach RA management in a patient who develops a new solid tumor while on therapy?
Risk-benefit ratios need to be individually assessed. There are several aspects to take into account: Choice of DMARD - Data on impact of various DMARDS on cancer recurrence or progression is scarce, especially for patients with active cancer. In general, there are few concerns for conventional DMA...
How do you approach treatment of a patient with active RA and a history of Lynch Syndrome?
The presence of hereditary polyposis coli and its predisposition to colon cancer should have little effect on the management of RA. Available data indicate that methotrexate has at best a neutral effect on predisposition to malignancy. There are data to suggest that the combination of methotrexate a...
Do you recommend genetic screening for FMF in asymptomatic first-degree relatives with a strong family history (multiple family members, severe/refractory disease)?
In the absence of FMF symptoms, it is not necessary to obtain genetics in first-degree relatives of patients with FMF. More critical than genetics is to screen for systemic inflammation and amyloidosis, which I would consider doing. I would check inflammatory markers and urinalysis with urine protei...
Do you restrict topical diclofenac use in your patients with chronic kidney disease?
It is a great question. I normally don't but I always do it with a touch of hesitation. I believe the absorption is minimal but it also depends of the degree of use. At this time, when narcotics are in restricted use and oral NSAIDs are not a good option in patients with CKD, topical NSAIDs may be t...