Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
Excluding CLL, in which patients would you screen for hypogammaglobulinemia?
Patients I screen for hypogammaglobulinemia include those with: gammaglobulin gap (total protein-albumin) less than two; advanced multiple myeloma or mantle cell lymphoma; patients who have received CAR T cells or bispecific antibodies against BCMA or CD20.
What's the best treatment for calcinosis universalis in a scleroderma patient?
This is a very challenging question since there is no standardized approach to the management of calcinosis. Calcinosis Universalis describes extensive calcific deposits with expanded bands or sheets of calcification seen mainly in juvenile dermatomyositis. In scleroderma, the calcific deposits are ...
How do you approach medication management in biopsy-proven pulmonary sarcoidosis with disease stable for over 2 years on hydroxychloroquine and low dose prednisone?
Well articulated by a card-carrying rheumatologist! I agree completely with Dr. @Dr. First Last’s commentary and would like to add some additional thoughts and observations. Steroid requirements can be, in fact, viewed as a biomarker of disease. If a patient is found to require even low-dose predni...
What is your approach to management of pulmonary fibrosis in patients with a history of microscopic polyangiitis who do not have other active organ involvement?
ILD is an important organ manifestation in AAV, typically seen in patients with MPO-ANCA where ~20% of patients have ILD which often precedes the diagnosis of AAV. The most common radiographic pattern is UIP. ILD has been associated with a higher risk of mortality in AAV in multiple series including...
How do you approach management of osteoporosis in patients post lung transplant?
Osteoporosis in patients with lung transplants is essentially glucocorticoid-induced osteoporosis. Most patients with severe lung disease have a long history of glucocorticoid exposure. Post-transplant, these patients are often on long-term glucocorticoids. The primary pathophysiology of chronic glu...
How do you approach management of patients with psoriatic arthritis who have significant improvement in skin disease, but ongoing inflammatory arthritis despite multiple DMARDs and/or biologics?
Psoriatic arthritis is a heterogeneous disease and often the severity of MSK involvement and psoriasis are not well correlated. This is also true regarding treatment response. The approach to management in these cases depends on several factors:Psoriasis type and severity: If the patient has mild ps...
What is the typical work-up completed to rule out other conditions prior to making a diagnosis of fibromyalgia (other than history and physical exam)?
I agree with Don and will just add a few things. The workup to a large part depends on how long the person has had similar symptoms. In an individual who has had many regional pain conditions and lifelong issues with sleep, fatigue, or other symptoms of FM, there is very little work up needed. Howev...
How would you counsel a patient with systemic sclerosis who wants to consider microneedling on the face or other skin which is not clearly involved with scleroderma?
Microneedling is a cosmetic procedure that utilizes multiple small needles to create tiny holes in the skin that stimulate the skin’s own "healing process", which, entails the production of collagen and elastin. While regardless of the specific device used, it is considered a relatively safe procedu...