Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to the workup for an underlying systemic condition in a patient presenting with retinal vasculitis?
Retinal vasculitis is a frequently misunderstood condition. My colleagues and I have written about it on several occasions such as in Current Opinion in Rheumatology, 2016. Retinal vasculitis is often diagnosed by an ophthalmologist on the basis of vascular leakage in a test called a fluorescein ang...
How do you manage occlusive bilateral retinal vasculitis with isolated lupus anticoagulant positivity?
Although I consider myself an expert on retinal vasculitis, I would often solicit help from a physician with expertise in coagulation, especially if that expertise is related specifically to the lupus anticoagulant. A tremendous part of the treatment strategy depends on the location and severity of ...
What lab markers are helpful for monitoring polymyalgia rheumatica patients on tocilizumab?
Based on the evidence supporting the use of tocilizumab (TOC) for the treatment of GCA, a number of small clinical trials have presented early data regarding its use for the treatment of PMR. Before we all jump on this bandwagon, we should carefully review the rationale for using TOC to treat PMR.Fi...
Would you consider using a TNFi in a patient with a family history of demyelinating disease, in the absence of a personal history?
No contraindication based on family history of MS that I am aware of. One could consider MRI head to rule out radiologically isolated syndrome, as a biomarker of risk.
How long do you maintain patients with anti-synthetase syndrome on Rituximab?
This is a challenging question to address, as there are no evidence-based guidelines, and multiple approaches may be attempted. My practice is that once the patient has been stable for at least 6–12 months, and after discussing the risk of flare with them, I attempt to reduce immunosuppression. For ...
Would you discontinue romosozumab in a patient who develops a hemorrhagic stroke while on therapy?
Considering the boxed warning to stop Evenity in a patient who has a stroke or MI while receiving it, yes, I would stop it. It is the prudent thing to do. However, I know of no evidence of harm with continuing it, and I might consider continuing it if the balance of benefits and risks were overwhelm...
How do you go about switching from one DMARD to another In patients with dermatomyositis that remains active?
Typically, we are adding additional drugs in combination to get response. Once we get response then we try to taper down the first DMARD slow until off. If first DMARD, didn't work at all, then we would stop the first and quickly untitrate another one, but that scenarios is uncommon.
Would you escalate treatment for a patient with Crohn disease with changes suggestive of chronic sacroiliitis on MRI but without bone marrow edema or effusion that suggests active inflammation?
I do not quite understand what escalation of treatment you are referring to. However, sacroiliitis needs to be treated depending on the patient's clinical presentation and symptoms. There was a study done with etanercept by Maksymowych et al., PMID 33514428.This study revealed that if erosions are p...
How do you manage osteoporosis treatment following parathyroidectomy for primary hyperparathyroidism?
Good question and I usually do this with input from an endocrinologist. I monitor serum and urine calcium and provide supplements and if the bone mass declines, I consult an endocrinologist on the next steps. As a rheumatologist, I am not an expert on this issue.
How do you approach the workup of clinically diagnosed cutaneous vasculitis in healthy young individuals without systemic symptoms?
As with all of medicine this answer depends on the presentation. A thorough review of systems and exam is needed to stratify workup. If we are talking about classic LCV below the knee in an otherwise healthy person, with no other concerning s/sx (as sounds like you are asking), I do generally confir...