Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you discuss sexual health with pediatric patients transitioning to adult rheumatology care when the patient is accompanied by parents or caregiver?
One of the most important aspects of transition is taking the time alone with the patient to ask questions confidentially. Best practice in pediatric rheumatology care is to have part of the clinic visit conducted with the patient alone- often, this is the opportunity to ask age relevant questions (...
What treatment options would you consider for a young patient with limited mobility, low bone mass and multiple vertebral compression fractures who is on dialysis for advanced kidney disease?
There are a lot of variables to this question. I would worry that the person may have a variant of OI (osteogenesis imperfecta) or some other collage problem and then add renal failure to the mix. I would try to establish the causes of each problem first such as steroid induced bone disease or a bon...
How do you approach long term management of glucocorticoid-induced osteoporosis in patients who develop osteonecrosis of the jaw on antiresorptive agent?
Osteonecrosis of the jaw is a rare complication of anti-resorptives with the exception of high doses used for cancer patients. Teriparatide (TPTD) has been anecdotally reported to assist in healing of ONJ. The patient described remains on glucocorticoids and is at very high risk for fracture, especi...
Would you transition from denosumab to anabolic agents in patients who are in urgent need for extensive dental work?
From my experience, this is a catch-22. If you stop the Denosumab you will markedly increase osteoclastic activity throughout the entire skeleton which is why it is recommended that you not stop the medication without some other intervention. I have had several patients with either osteonecrosis of ...
What is the role of non-prednisone oral glucocorticoids in the management of systemic rheumatologic disease?
I saw this question and thought it was really interesting. I did some preliminary research on the topic and was amazed at how little is actually written in the scientific literature. Perhaps someone reading this can perform a search and offer some thoughts. I decided to write to start a dialogue on ...
Do you routinely use anti-resorptive medications in patients who have osteoporosis and longstanding hypoparathyroidism?
If a patient has hypoparathyroidism, I am unwilling to use bisphosphonates or denosumab because of fear of significant hypocalcemia. I will use other agents to treat their osteoporosis.
What is your approach to dosing and duration of rituximab for refractory lupus nephritis not responsive to cyclophosphamide or mycophenolate?
FirstThe question specifically states "not responsive." It would be highly improbable not to have some improvement with these therapies in conjunction with using hydroxychloroquine (HCQ), steroids, ACE inhibitors, ARBs, and sodium-glucose cotransporter 2 (SGLT2) inhibitors in an adherent patient.Wha...
What is your approach to tapering therapy in patients with pulmonary sarcoidosis who are asymptomatic with stable pulmonary function and imaging?
We generally do not use weight-based dosing for treating sarcoidosis but often will use 20 mg daily (0.25 mg/kg) as a starting point. If a patient is newly started on prednisone, then we may use a gradual taper 20 mg daily for 1 month, then 15 mg daily for 1 month, then 10 mg daily until they are re...
Do you recommend a particular antiresorptive/anabolic agent for patients who are at high risk for fractures but have high risk of osteonecrosis of the jaw?
Teriparatide has improved bone healing in patients with osteonecrosis of the jaw, so would be a good choice for patients at high risk of ONJ.
What are your practice recommendations regarding live vaccinations in infants/children of women who are currently on DMARDs and are breastfeeding?
This question needs some clarification to provide an exact answer. However, in regards to DMARDs in lactation, per the ACR 2020 Reproductive Health Guidelines and resources like LactMed and Mother to Baby (both free!), Methotrexate, Leflunomide, and Mycophenolate are not recommended in lactation. Th...