Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
How do you approach treating and monitoring sarcoidosis manifested by maxillary bone/teeth loss without other symptoms?
I'm very curious how this was determined to be sarcoidosis. Has a PET been done to determine whether this is the only site? Other entities evaluated for like CRMO? Obviously, neoplasm and infection are also important to rule out before immunosuppressive treatment. Conversely, with our limited "tool ...
What is your approach to the management of shrinking lung syndrome in SLE?
I agree with the approach laid out by Dr. @Dr. First Last. As with Dr. @Dr. First Last, we rarely see it, maybe once a year. The only thing I can add is whether the patient is overweight. I have a young man with lupus and shortness of breath who we evaluated and he has restrictive lung disease with ...
What steroid sparing agent do you use for treatment of cardiac sarcoidosis?
Recognizing that corticosteroids will be needed to acutely stabilize cardiac sarcoidosis, a steroid sparing agent is usually a reasonable choice early. My choice of secondary agents depends on the other manifestations of sarcoidosis present at the time of diagnosis. I have rarely seen cardiac sarcoi...
Would you escalate treatment for a clinically stable/asymptomatic lupus patient with persistent leukopenia/neutropenia, already on hydroxychloroquine?
The short answer is it depends on several variables most importantly, whether the patient has been experiencing recurrent infections. Additionally, the presence or absence of coincidental lymphocytopenia can be relevant. Worth mentioning that the most common hematologic manifestations in lupus are a...
What is your approach to the management of Bell's palsy that has not improved after six months?
My understanding is that 'Bell's palsy' means idiopathic facial palsy. Therefore, I usually evaluate for other causes, depending on the clinical scenario, before calling it Bell's palsy. We see a lot of Lyme disease in PA. Facial palsy may be the initial manifestation of neurosarcoidosis and may res...
Does your institution have formal policies or work flows to reduce unnecessary IGRAs ordered for patients on biologics?
We have developed a multi-specialty working group to implement this as a lot of unnecessary testing is getting done. This will include having a 2-3 question screening pre start of biologics, and then annually to asses risk, that we hope will be incorporated into the visit or an order set.
How would you manage a patient with symptomatic Paget’s disease and osteoporosis who developed new fragility fractures while on Fosamax?
This is a complicated patient, and symptomatic Paget's needs more information. But given one wants to treat the Paget's and there are fragility fractures I would give an injection of Zoledronic Acid (mostly for the Paget's) and if needed, start Romosozumab for the fragility fractures. However, I wou...
How would you approach a finding of osteoporosis (Z score -4.5) in a recently postpartum patient who had DEXA sent for long-term low-dose glucocorticoid use?
Ensure adequate calcium, vitamin D, and magnesium. I would check the PTH level and a 24-hour urine for calcium and creatinine.