Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend adjusted adult cancer screening for patients who have been on long term biologics and/or tsDMARDs since childhood?
I recommend routine adult cancer screening with the exception that I suggest annual dermatology evaluation for patients who are taking chronic immunosuppression.
What is your approach in differentiating IPAF (interstitial pneumonia with autoimmune features) versus "CTD ILD" in patients with serologic abnormalities but do not fulfill criteria for autoimmune disease?
Even for those of us who work in ILD clinics, this can be a challenging issue. The concept of IPAF (interstitial pneumonia with autoimmune features) was developed in 2015 jointly by the ATS and the ERS for study purposes and as such is somewhat helpful in the clinic. Much like classification criteri...
Does synovial biopsy provide diagnostic value in undifferentiated inflammatory arthritis?
Currently, a synovial biopsy cannot reliably distinguish undifferentiated inflammatory arthritis. Work on this topic is ongoing, and there is reason to hope that biopsy findings may someday provide useful information regarding the pathology and treatment of various types of arthritis.Donlin et al., ...
When do you recommend using trabecular bone score (TBS) for managing osteoporosis?
Trabecular bone score is a valuable tool in the evaluation of osteoporosis and risk of fracture. It is an indirect indicator of bone microarchitecture. Although TBS predicts fracture risk, it should not be used alone but in conjunction with BMD for deciding whether to treat the osteoporosis and if s...
How do you approach follow up of young patients with isolated +ANA, but no current clinical signs or symptoms of SLE?
An old study showed that ANA can be positive in patients who develop lupus up to 9 years (average 3 years) before the onset of clinical disease but it was not necessarily isolated ANA as Ro and La antibodies could also be detected long before the onset of the disease (Arbuckle et al., PMID 14561795)...
Do you prefer celecoxib over a nonselective NSAID in patients with chronic kidney disease?
There are many potential advantages of celecoxib, as a "selective" COX-2 inhibitor, over non-selective NSAIDs. Because of the lesser inhibition of platelet function, it has potential advantages in the peri-operative period, in patients with bleeding disorders or taking anti-thrombotic or anti-coagul...
Which steroid-sparing agent do you prefer to treat multi-organ Sweet's syndrome?
I have used methotrexate in combination with cyclosporine with some success but am most impressed with the effect of anakinra to control disease and allow discontinuation of corticosteroids. I would also recommend them in that order.
How do you approach management of adult patients with CVID and sarcoid-like syndrome?
Common variable immunodeficiency syndrome (CVID) is the most common primary immunodeficiency, and is of course, characterized by recurrent infections. This can lead to bronchiectasis due to structural damage from these recurrent infections. However, patients can also have non-infectious manifestatio...
What is your experience with using oral deucravacitinib off label for conditions such as recalcitrant facial discoid lupus or recalcitrant lichen planus?
This is an excellent question and importantly highlights the potential for newer therapies to help treat challenging diseases with few if any FDA approved options. In the case of DLE, I have found deucravacitinib to be a good option, sometimes as monotherapy or perhaps in conjunction with other topi...
What is your approach to counseling patients regarding re-initiation of anti-TNF therapy after completion of treatment for non-disseminated pulmonary histoplasmosis?
We published a retrospective study on this topic in 2015 (Vergidis et al., PMID 25870331). We concluded that resumption of TNF-alpha antagonist therapy may be considered in individuals treated for histoplasmosis who have no evidence of residual disease and undetectable Histoplasma antigen levels. We...