Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you manage patients with severe hand OA (no synovitis on exam, negative serologies) who fail to respond to NSAIDs but respond very well to oral steroids?
I have used Hydroxychloroquine with some success and offer that to patients for a trial for 4 months if they are willing.
For patients <65 with significant intermittent steroid exposure who otherwise do not have risk factors for osteoporosis, when, if ever, do you recommend considering DEXA screening?
The FRAX guidelines recommend answering "Yes" for glucocorticoid use when a patient has received the equivalent of prednisone ≥5 mg daily for more than 3 months. However, many patients with rheumatoid arthritis have been treated with intermittent courses of corticosteroids over several years, which ...
How do you approach laboratory evaluation in patients with fatigue?
First search for evidence by history and physical examination for any evidence of inflammation. If there is tailor the lab workup rather than ordering tests as screening tools. ESR and CRP to start with. Anything more without a reasonable a priori likelihood of the targeted diagnosis is just asking ...
When should patients with diabetes mellitus be screened for osteoporosis?
Hip fracture risk is higher in patients with diabetes (T1DM almost 7 times and T2DM 38% higher than controls without diabetes) (Vestergaard, PMID 17068657), and BMD scores underestimate true risk. That has led the ADA to suggest considering treatment for bone densities with T-score <-2.0, rather tha...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
How should the results of the ADVOCATE trial be applied in AAV patients who receive rituximab induction and maintenance therapy?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:The data from ADVOCATE indicate that patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) treated with avacopan 30 mg twice daily and prednisone placebo were able to achieve remission w...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
Do you recommend medical therapy for extensive atraumatic osteonecrosis of the femoral head to mitigate pain or prevent femoral head collapse?
This is a good question. Extensive atraumatic ON of the femoral head will probably not respond to any medical therapy; eventually, the patient will need a replacement. However, ON that is from a systemic insult (drugs, alcohol) is often bilateral so if the other hip is less affected or not affected,...
What additional workup and steroid-sparing option would you choose in a patient with potential medium-vessel vasculitis (petechial rash, sensorimotor neuropathy, renal infarcts, renal artery micro-aneurysms and ischemic/ulcerative duodenitis), hypocomplementemia, ASO 1525, negative blood cultures and normal echo?
This is a challenging case. Generally, PAN should be confirmed histologically, particularly if there are atypical features. In this case, hypocomplementemia is atypical, as non-HBV-associated PAN is generally normocomplementemic. Further, PAN more commonly causes ulcers/nodules/reticular lesions tha...