Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach management of a young male patient with discoid lupus who has had minimal response to hydroxychloroquine (and subtherapeutic whole blood levels) who continues to use tobacco products?
First, is he taking his HCQ (55% chance he is not)? Check a trough whole blood HCQ drug level and you want it to be 1000 - 1200 ng/mL (that is my goal in uncontrolled lupus; 750 - 1200 is fine in lupus under remission per Garg et al., PMID 37667434). Thanks, @Dr. First Last for reminding me. :-) Wh...
Do you find HZV titers useful in diagnosing shingles sine herpete?
VZV sine herpete is an infection/disorder frequently considered but rarely confirmed and represents an atypical presentation of VZV reactivation in the cranial nerve, spinal nerve, viscera, or CNS in the absence of classic cutaneous findings.Serum IgG VZV in isolation is not useful unless followed s...
What is your approach to work up for patients referred for early onset osteoarthritis?
Great question and one that comes up fairly often. I created a mnemonic for causes of "secondary osteoarthritis" & these etiologies drive the workup - this might be appropriate for a person with OA in an unusual place or who is unusually young for having it. Here it is: THE CHARMING T- trauma H - ...
Do you avoid hyaluronic acid injections in patients with chondrocalcinosis on imaging?
The association between viscosupplementation and CPPD flares is reported but not truly well studied. There is a nice case series by Bernardeau et al., PMID 11302877 entitled “Acute arthritis after intra-articular hyaluronate injection: onset of effusions without crystals” in Ann Rheum Dis 2001;60:51...
How are you utilizing vibratory devices for reducing pain associated with injection or procedures?
Specifically for intra-articular/bursal/tenosynovial/carpal tunnel injections: Our office purchased the vibration distraction devices over a decade ago based upon the promising use from the pediatric literature. Our providers were underwhelmed with their use in our adult patients and we all stopped ...
Are there situations in which you treat calcinosis cutis that is not symptomatic for the patient?
There is NO treatment for either the prevention of calcinosis or the dissolution of calcinosis. Every 5-10 years over the past 40 years there have been potential treatments but none have been confirmed. I do not use anything specific for the asymptomatic patient. I do rarely recommend surgery by an ...
How would you approach management of a patient with rapidly progressive systemic sclerosis with worsening skin disease, myositis, arthritis, dysphagia and failure to thrive developing within 6 months?
This is a unique subset of patients with very aggressive disease and high risk for poor outcomes with myopathy, poor GI dysmotility, at risk for early PH. We tend to treat them aggressively. I would consider rapid escalation of immunosuppression such as MMF and consider IVIG up front as well, especi...
What is your approach to treating osteoporosis in patients post bariatric surgery?
While there is no guidance from the bariatric surgeons, I tend to avoid oral bisphosphonates in all patients with prior bariatric surgery. I am worried about the pill getting stuck independent of the type of surgery. Since we have IV bisphosphonates and denosumab I have good alternatives to oral bis...
What are some strategies to help teach patients transitioning from pediatric to adult care to become more independent with respect to their care and less dependent on their caregivers?
A framework that has been helpful is Got Transition® that provides a structure for the approach in implementing a transition process. It is divided into areas to help health care providers, youth and young adults, parents and caregivers. Numerous resources are available for all stakeholders that inc...
What are some important considerations for use of ACE inhibition in scleroderma renal crisis patients who require dialysis?
Yes, captopril is dialyzable with about ~35% of the drug being removed during intermittent hemodialysis. It is not recommended to be used if an AN69 hemofilter is used for iHD, as it is associated with anaphylaxis with that particular filter. There does not appear to be any contraindications to usi...