Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you counsel an early stage breast cancer patient with lupus regarding decisions on radiation?
The data with lupus and RT is not consistent and most recent data suggest good tolerance to breast RT. I have them continue on medication for lupus and counsel them that acute morbidity and late effects appear to similar although there is some chance it may be enhanced but not contraindication to RT...
What is your approach to initial assessment of disease extent in patients with Behcet's disease?
As Behcet's syndrome is a clinical diagnosis, the symptoms that a patient presents with dictates the initial assessment, for the most part. A lot of work up is needed to rule out other conditions that may mimic Behcet's syndrome, however, assuming that has been done, evaluation for eye involvement b...
How important do you feel HLAB51 testing is in diagnosing Behcet's disease?
The diagnosis of Behcet syndrome is based on clinical signs and symptoms. Laboratory testing and imaging studies are usually used to rule out conditions that may mimic Behcet rather than confirm the diagnosis. There is a strong genetic association between HLA-B51 and Behcet. About 50–80% of Behcet p...
What is your first treatment of choice in patients with dermatomyositis sine myositis?
Great question! For better or worse, there isn't a great one-size-fits-all answer since choosing the "best" agent means assessing the severity of the disease, assessing if there are extracutaneous manifestations that also need to be addressed (e.g., interstitial lung disease? inflammatory arthritis?...
How do you transition to an anabolic agent in a patient who develops an atypical fracture while on denosumab?
It is not usual to suffer an atypical fracture of the femur from denosumab, however, they do occur. It is useful to start an anabolic agent, either abaloparatide or teriparatide for both augment fracture healing and to treat the osteoporosis. Both abaloparatide and teriparatide stimulate bone format...
How do you manage osteopenia, osteoporosis and calcium / Vit D supplementation in a patient with calcinosis?
Calcinosis is mineralization of the blood vessels. Currently, there is no evidence to support any association with circulating calcium levels and calcinosis. Therefore, calcium and vitamin D supplementation at recommended levels for age will not increase calcinosis. Also, remember that ASCVD, renal ...
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...