Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
What is the maximum dose of leucovorin that you use with methotrexate?
This question of folinic acid (leucovorin) dosing in the setting of methotrexate use is challenging to answer since the rationale for choosing leucovorin, the side effect prompting its choice and the dose of methotrexate is needed prior to answering the question.There is no clear literature-based re...
When transitioning from anabolic agent to denosumab, do you stop teriparatide 1 day prior to transition and romosozumab 1 month prior to transition?
I do not believe there is any comparison data to guide this question. My philosophy was to get denosumab going asap at the end of our scheduled anabolic course. I would often schedule a tptd or abaloparatide patient at 23 months to discuss denosumab and get the process started for approval. We often...
What range of musculoskeletal complaints have you seen with romosozumab use?
The most common side effect with Romo is injection site reactions. Some patients may have musculoskeletal pain but so do many patients not on Romo. Overall, I found that it is very well tolerated, but if a patient believes that it is causing major undesirable effects, then it is probably best to sto...
How do you approach immunosuppression in patients with a positive Interferon Gamma Release Assay and prior intravesicular BCG treatment for bladder cancer?
Bacillus Calmette–Guérin (BCG) is the most widely used vaccine worldwide and has been used to prevent tuberculosis for a century. BCG also stimulates an anti-tumor immune response, which urologists have harnessed for the treatment of non-muscle-invasive bladder cancer. As rheumatologists, we occasio...
How do you determine when to transition off pegloticase to other uric acid lowering therapies?
When to transition patients off of pegloticase is a question that is frequently posed to me by my colleagues and by my patients. Pegloticase is not a drug meant for long-term therapy but rather to achieve specific targeted clinical outcomes. I usually recommend once those outcomes are achieved, that...
What is the appropriate management of arthralgias associated with bosutinib?
Arthralgias have been reportedly associated with the use of all TKIs. The mechanism of this adverse event is not clear. Most of them respond to management with anti-inflammatory agents. When very severe (e.g., grade 3 or 4) transient treatment interruptions and dose reductions may be indicated. In s...
How would you approach asymptomatic hepatic sarcoid?
Hepatic involvement in sarcoidosis is very common. In old autopsy series, as many as 70% of unselected cases of sarcoidosis were found to have granulomatous inflammation in the liver. Today, many possible cases are identified incidentally by more advanced diagnostic testing techniques such as PET sc...
Is the efficacy and dose same for subcutaneous vs intravenous IVIGs being used for dermatomyositis?
Thank you for the very interesting question:When considering the best answer, there is a bit of background I think is important to keep in mind. (I'll put my final thoughts about dosing at the end of this background) First and foremost, although IVIG has been used as a de facto treatment for multipl...
Have you been able to safely use other bisphosphonates in patients who developed an allergic reaction (angioedema) to fosamax?
Hypersensitivity with urticaria in someone on alendronate is quite rare. I am not aware of any publications showing another bisphosphonate safely used in this setting. Although there are significant chemical differences between the various oral and IV bisphosphonates, I personally would avoid the en...