Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider using a TNFi in a patient with a family history of demyelinating disease, in the absence of a personal history?
No contraindication based on family history of MS that I am aware of. One could consider MRI head to rule out radiologically isolated syndrome, as a biomarker of risk.
How long do you maintain patients with anti-synthetase syndrome on Rituximab?
This is a challenging question to address, as there are no evidence-based guidelines, and multiple approaches may be attempted. My practice is that once the patient has been stable for at least 6–12 months, and after discussing the risk of flare with them, I attempt to reduce immunosuppression. For ...
Would you discontinue romosozumab in a patient who develops a hemorrhagic stroke while on therapy?
Considering the boxed warning to stop Evenity in a patient who has a stroke or MI while receiving it, yes, I would stop it. It is the prudent thing to do. However, I know of no evidence of harm with continuing it, and I might consider continuing it if the balance of benefits and risks were overwhelm...
How do you go about switching from one DMARD to another In patients with dermatomyositis that remains active?
Typically, we are adding additional drugs in combination to get response. Once we get response then we try to taper down the first DMARD slow until off. If first DMARD, didn't work at all, then we would stop the first and quickly untitrate another one, but that scenarios is uncommon.
Would you escalate treatment for a patient with Crohn disease with changes suggestive of chronic sacroiliitis on MRI but without bone marrow edema or effusion that suggests active inflammation?
I do not quite understand what escalation of treatment you are referring to. However, sacroiliitis needs to be treated depending on the patient's clinical presentation and symptoms. There was a study done with etanercept by Maksymowych et al., PMID 33514428.This study revealed that if erosions are p...
How do you manage osteoporosis treatment following parathyroidectomy for primary hyperparathyroidism?
Good question and I usually do this with input from an endocrinologist. I monitor serum and urine calcium and provide supplements and if the bone mass declines, I consult an endocrinologist on the next steps. As a rheumatologist, I am not an expert on this issue.
How do you approach the workup of clinically diagnosed cutaneous vasculitis in healthy young individuals without systemic symptoms?
As with all of medicine this answer depends on the presentation. A thorough review of systems and exam is needed to stratify workup. If we are talking about classic LCV below the knee in an otherwise healthy person, with no other concerning s/sx (as sounds like you are asking), I do generally confir...
How do you decide when to obtain genetic testing for suspected autoinflammatory conditions in adults?
We have identified an autoinflammatory disorder that occurs in people of the Southern Appalachian mountains known as "Melungeons." Several have been evaluated at NIH, and while they do not have any of the known markers the diagnosis of familial Mediterranean fever has been confirmed. Dr. Kastner tol...
What would be the preferred treatment option for PMR if patient develops gastric perforation soon after initiation of steroids?
Of course Kevzara.
How would you approach the workup and management of a young patient with recurrent biannual non-scarring oral ulcers and new onset neurologic symptoms with associated CNS white matter lesions concerning for Behcet’s?
This is a challenging case. It should be noted that oral ulcers in Behcet's typically occur more than twice per year (by ISG criteria should occur at least 3x per year) and without other symptoms of BD it can be very challenging to make a probable diagnosis of BD in this scenario. A careful history ...