Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you avoid intra-articular and bursa/tendon sheath corticosteroid injections in patients with a history of avascular necrosis?
I would give intra-articular or bursa injections of steroids/glucocorticoids in patients with either active ON or a history of GC induced ON. I do not believe the local injection will increase the risk of progression or incident ON, as long as it is not given more often than every 3-4 months.
Should the age at which patients transition from pediatric to adult care differ depending on the disease diagnosis?
First, a distinction needs to be made between transition (which is a long-term, ongoing process) and transfer of care (which is the act of going to one provider to another). Transition introduction should start early, with recommendations that age 12 is a good beginning to introduce the concepts of ...
How do you counsel patients about the risk of osteonecrosis of the jaw with anabolic agents such as teriparatide or romosozumab ?
Drug-induced osteonecrosis of the jaw (ONJ) has been reported to occur with all anti-resorptive osteoporosis medications. Romosozumab has a dual mechanism of actions with both anabolic (bone building) and anti-resorptive effects. In a double-blind, placebo-controlled study involving 3321 subjects wh...
Do you combine methotrexate and leflunomide for the treatment of RA?
Absolutely! What a coincidence, as I was just communicating by email with a patient with horrible hard-to-control psoriatic arthritis (PsA) who failed numerous combos and biologics. (I know this question is RA, but also think of LEF with PsA). It was not until I added leflunomide (LEF) to her regime...
What is the maximum dose of leucovorin that you use with methotrexate?
This question of folinic acid (leucovorin) dosing in the setting of methotrexate use is challenging to answer since the rationale for choosing leucovorin, the side effect prompting its choice and the dose of methotrexate is needed prior to answering the question.There is no clear literature-based re...
When transitioning from anabolic agent to denosumab, do you stop teriparatide 1 day prior to transition and romosozumab 1 month prior to transition?
I do not believe there is any comparison data to guide this question. My philosophy was to get denosumab going asap at the end of our scheduled anabolic course. I would often schedule a tptd or abaloparatide patient at 23 months to discuss denosumab and get the process started for approval. We often...
What range of musculoskeletal complaints have you seen with romosozumab use?
The most common side effect with Romo is injection site reactions. Some patients may have musculoskeletal pain but so do many patients not on Romo. Overall, I found that it is very well tolerated, but if a patient believes that it is causing major undesirable effects, then it is probably best to sto...
How do you approach immunosuppression in patients with a positive Interferon Gamma Release Assay and prior intravesicular BCG treatment for bladder cancer?
Bacillus Calmette–Guérin (BCG) is the most widely used vaccine worldwide and has been used to prevent tuberculosis for a century. BCG also stimulates an anti-tumor immune response, which urologists have harnessed for the treatment of non-muscle-invasive bladder cancer. As rheumatologists, we occasio...
How do you determine when to transition off pegloticase to other uric acid lowering therapies?
When to transition patients off of pegloticase is a question that is frequently posed to me by my colleagues and by my patients. Pegloticase is not a drug meant for long-term therapy but rather to achieve specific targeted clinical outcomes. I usually recommend once those outcomes are achieved, that...
What is the appropriate management of arthralgias associated with bosutinib?
Arthralgias have been reportedly associated with the use of all TKIs. The mechanism of this adverse event is not clear. Most of them respond to management with anti-inflammatory agents. When very severe (e.g., grade 3 or 4) transient treatment interruptions and dose reductions may be indicated. In s...