Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
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?
Epidemiologic studies in sarcoidosis show that the majority of sarcoid cases are benign. Some patients can have disease remission, and therefore are able to come off of therapy. Most of this data is in pulmonary sarcoidosis and the data is less clear when there is other organ involvement. The diseas...
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...