Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?
Some recommendations call for completing a course of treatment for latent TB prior to starting a biologic but I find most patients and referring specialists are intolerant of that strategy. This reference: Yeo et al., European Respiratory Journal 2014 is a good example of data supporting a shorter w...
When is a biopsy necessary to diagnose relapsing polychondritis?
Since there are no specific lab tests for Relapsing Polychondritis, the diagnosis is based on clinical manifestations. Criteria proposed by McAdam et al. PMID 775252 require three or more of the following clinical features to confirm the diagnosis: Bilateral auricular chondritis Non-erosive, seroneg...
Do you consider immunosuppressive agents in progressive interstitial pneumonias or pneumonitis without a clear driving etiology?
Although it's often helpful to have a clear diagnosis of an underlying connective tissue disease (CTD) or positive autoantibodies to guide therapy (or perhaps feel better about prescribing it), we more often find ourselves dealing with ambiguous cases. When pathology is available to suggest an infla...
Do you recommend treatment of worsening skin thickening with Limited Scleroderma +ANA+centromere and if so with what agent would you use?
There really have not been adequate trials in patients with limited cutaneous scleroderma as far as the effectiveness of medication for 'worsening' skin thickening. In this situation, it is not clear since the patient likely has a long-standing disease, really has worse skin thickening and where is ...
What would be your approach to a patient with Scleroderma/Myositis overlap syndrome (+anti-Ku) and active inflammatory eye disease despite high dose mycophenolate?
This is a challenging question but impossible to answer without more information. Inflammatory eye disease includes uveitis, scleritis, corneal melt, and orbital inflammation. Just as scleroderma itself has a range of manifestations that drive the treatment, the various eye inflammations would requi...
What protective post-op measures do you recommend for a patient with scleroderma and a history of ILD, PH, Raynaud’s and digital ischemia undergoing cardiothoracic surgery?
Appropriate post-operative care in patients with scleroderma is very important. In the context of the cardiopulmonary disease, volume management is very important with close monitoring in I/O's to optimize fluid status. In a patient with a history of digital ischemia, it is important to keep the pat...
How do you approach medication management in patients with RA when transitioning from csDMARD triple therapy to anti-TNF?
There is not a one-size-fits-all approach to this question. Drug transitions can be influenced by several factors including individual side effects of medications, patient preference for other reasons, disease co-morbidities, ability to use prednisone as bridge therapy, etc. In general, hydroxychlor...
Would you stop azathioprine in a patient with ANCA vasculitis who has been in long term remission on azathioprine, but has a new diagnosis of lung cancer requiring initiation of immunotherapy?
Data about the effect of immunosuppression on the efficacy of immune checkpoint inhibitors suggests that there is a negative of effect of being on immunosuppression at the time of ICI initiation on tumor response. So if the patient really has been clinically stable for a long time there are a few op...
Have the results of the ancillary study of the VITAL trial, demonstrating that Vitamin D3 supplementation did not reduce the incident rate of fractures in generally healthy midlife and older adults, changed how you prescribe Vitamin D?
It should be appreciated that the function of vitamin D is to maintain a serum calcium concentration in a normal range to maintain neuromuscular function and most metabolic functions. It can accomplish this by increasing intestinal calcium absorption. When there is inadequate calcium in the diet, th...
Would you consider teriparatide use in a patient with prior radiation therapy, given that the black box warning regarding osteosarcoma risk has been removed by the FDA?
The rat studies were unequivocal that both teriparatide and abaloparatide increased the risk of osteosarcoma in rats given high doses for essentially their entire lifespan. Upon approval of teriparatide, Lilly agreed to a post-marketing pharmacovigilance study that started out as a case-finding stud...