Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you avoid hyaluronic acid injections in patients with chondrocalcinosis on imaging?
The association between viscosupplementation and CPPD flares is reported but not truly well studied. There is a nice case series by Bernardeau et al., PMID 11302877 entitled “Acute arthritis after intra-articular hyaluronate injection: onset of effusions without crystals” in Ann Rheum Dis 2001;60:51...
How are you utilizing vibratory devices for reducing pain associated with injection or procedures?
Specifically for intra-articular/bursal/tenosynovial/carpal tunnel injections: Our office purchased the vibration distraction devices over a decade ago based upon the promising use from the pediatric literature. Our providers were underwhelmed with their use in our adult patients and we all stopped ...
Are there situations in which you treat calcinosis cutis that is not symptomatic for the patient?
There is NO treatment for either the prevention of calcinosis or the dissolution of calcinosis. Every 5-10 years over the past 40 years there have been potential treatments but none have been confirmed. I do not use anything specific for the asymptomatic patient. I do rarely recommend surgery by an ...
How would you approach management of a patient with rapidly progressive systemic sclerosis with worsening skin disease, myositis, arthritis, dysphagia and failure to thrive developing within 6 months?
This is a unique subset of patients with very aggressive disease and high risk for poor outcomes with myopathy, poor GI dysmotility, at risk for early PH. We tend to treat them aggressively. I would consider rapid escalation of immunosuppression such as MMF and consider IVIG up front as well, especi...
What is your approach to treating osteoporosis in patients post bariatric surgery?
While there is no guidance from the bariatric surgeons, I tend to avoid oral bisphosphonates in all patients with prior bariatric surgery. I am worried about the pill getting stuck independent of the type of surgery. Since we have IV bisphosphonates and denosumab I have good alternatives to oral bis...
What are some strategies to help teach patients transitioning from pediatric to adult care to become more independent with respect to their care and less dependent on their caregivers?
A framework that has been helpful is Got Transition® that provides a structure for the approach in implementing a transition process. It is divided into areas to help health care providers, youth and young adults, parents and caregivers. Numerous resources are available for all stakeholders that inc...
What are some important considerations for use of ACE inhibition in scleroderma renal crisis patients who require dialysis?
Yes, captopril is dialyzable with about ~35% of the drug being removed during intermittent hemodialysis. It is not recommended to be used if an AN69 hemofilter is used for iHD, as it is associated with anaphylaxis with that particular filter. There does not appear to be any contraindications to usi...
What disease activity measures do you find helpful in clinical practice for psoriatic arthritis/peripheral spondyloarthritis?
Treat to target strategy has been shown to improve patient outcomes in patients with PsA (TICOPA study). Therefore, it is important to set treatment targets and measure disease activity in clinical practice in PsA. Measuring disease activity in this disease is, however, challenging due to heterogene...
Should gonadotropin-releasing hormone (GnRH) agonists be offered to all women of reproductive age about to undergo treatment with cyclophosphamide?
I agree with @Dr. First Last's response with a caveat. Ovarian failure is more likely in patients receiving NIH dosing which is 0.5 -1 gram per meter squared of body surface area monthly as opposed to a fixed 500 mg low-dose every 2 weeks. The former in a typical female over six months would be 9 g ...
Any concern for lupus flare in patients undergoing laser hair removal?
Great question - no there is little concern for this because LHR wavelengths are not in the ultraviolet spectrum which is known to spark SLE flares. Even narrow-band UVB (phototherapy) has been used in SLE patients without much issue, however, this is controversial and some feel that depending on th...