Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
What is the utility of MRI for identifying disease activity in myositis patients when physical exam and labs are inconclusive?
Agree with @Dr. First Last, however, I want to caution about sensitivity and specificity of muscle MRI for a particular situation you are suggesting i.e., to evaluate if patient has active or inactive disease, has not been studied or proven. The muscle MRI, in general, has good sensitivity and speci...
How would you manage active psoriasis and psoriatic arthritis in patient on Rituximab and prednisone for MPO positive vasculitis?
The answer is it depends on several factors, the most important being how severe the psoriasis is and if the patient has axial involvement. Since the patient has failed or not responded to methotrexate or apremilast, adding these would not be an option here.While we do not have much data on combinat...
Would you offer lung SBRT for an individual with rheumatoid arthritis?
I wouldn't hesitate to use SBRT in this setting, all things being equal. The important caveats for "equal" are whether they have any component of interstitial lung disease. I'm very fortunate to have access to proton therapy, and about the only time I use it for SBRT lung is in patients with severe ...
Should methotrexate be categorically avoided in RA patients with COPD or RA-ILD?
Thanks for raising a very important question. It is something that every practicing Rheumatologist comes across several times during their career.The traditional teaching has always been to avoid using Methotrexate in patients with underlying pulmonary conditions due to the associated risk of Hypers...
Should MTX be avoided in RA patients with asymptomatic lung nodules?
It is well established that in some RA patients, methotrexate does cause accelerated nodulosis predominantly in the hands which improves after stopping the medication. That does not mean having pulmonary nodules is a contraindication to use methotrexate. I recommend doing frequent chest x-rays for m...
Is chronic methotrexate for rheumatoid arthritis a contraindication for prostate brachytherapy?
I would agree with Dr Rogers that there is really limited information with in the published literature to guide us in this specific clinical situation. In my personal experience I have recommended holding the methotrexate (if possible) prior to a planned course of external beam radiotherapy, HDR bra...
How do you treat multisystem sarcoidosis refractory to methotrexate, humira, and remicade?
There are many layers to this question because there are many possible explanations for treatment failure. The first issue to consider is whether the specific features of sarcoidosis being treated are best addressed through an immunosuppressive approach. Some manifestations of sarcoidosis may be ind...
Would you consider the use of an anabolic agent to promote fracture healing?
While there are no drugs FDA that are approved to enhance fracture healing, there is considerable literature and experience using the PTH-based anabolic drugs to attempt to heal a fracture. They are sometimes used in the setting of delayed union or non-union. They have been used in elite athletes to...
When would you suspect metabolic myopathy and what is your approach to initial workup?
Great question and really important to rheumatology practice. As always, a history and physical exam is the best initial diagnostic tool. It’s a little bit difficult because of the sheer number and heterogeneity of non-autoimmune myopathies that clinicians may encounter, but a few general principles...