Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In patients with isolated anti-Centromere antibody positivity and Raynaud's phenomenon without other features of systemic sclerosis, what is your approach to screening for pulmonary complications?
In patients with isolated anti-centromere antibody (ACA) positivity and Raynaud's phenomenon, even without overt systemic sclerosis, the primary concern is pulmonary arterial hypertension (PAH), which can develop at any point, including decades after initial presentation. Notably, ACA-positive patie...
In patients with lupus nephritis, and MAHA with positive anti-phospholipid autoantibodies, what are the considerations to use or not use anti-coagulation therapy?
I support anticoagulation and C5 inhibition for such patients if they are not adequately responding.
In what clinical situations do you consider azathioprine for treatment of inflammatory arthritis?
Azathioprine (AZA) is among the oldest pharmacologic immunosuppressive agents in use today. Initially developed as a long-lived prodrug of 6-mercaptopurine (6-MP), it was quickly found to have a more favorable therapeutic index. Gertrude B. Elion (Winner of 1988 Nobel Prize in Medicine for “importa...
How do you approach work up for underlying rheumatologic disease in patients referred for chronic urticaria?
Chronic urticaria (6 weeks or longer) is often a self-limited disorder seemingly idiopathic in etiology. There are certain autoimmune disease more prevalent in patients with chronic urticaria including systemic lupus erythematosus, Sjogren's syndrome, autoimmune thyroid disease, celiac sprue, and rh...
How do you work with patients to establish reasonable treatment goals for the management of fibromyalgia-related pain?
Great question. I explicitly tell my patients that I have no magic-bullet– no penicillin or prednisone-adjacent pill – that will swiftly and reliably alleviate their pain. This expectation, that a pill will eradicate disease, makes sense in the wake of the infectious disease revolution, where target...
How do you utilize tools such as MMT8 in clinical practice when evaluating myositis?
We test hip flexors in every patient as well as the traditional muscles tested in MMT-8. I agree that it is not ideal that MMT-8 does not include these muscles. In fact, we test all large muscle groups - UE and LE as well as the finger flexors and extensors for complete assessment - then extrapolate...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
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 ...
Do you recommend patients hold folic acid on the day they take methotrexate?
The proposed mechanism of action (MOA) of methotrexate in rheumatic disease is not from the antimetabolite angle (given its oncologic MOA as a dihydrofolic acid reductase inhibitor), but rather as a potent anti-inflammatory and immunomodulatory medication through the MOA of extracellular adenosine a...
For patients with evidence of prior bilateral uveitis (PS, pupillary membranes, inactive KP, no view posteriorly) who reports no prior symptoms and who has had negative lab work-up, when do you consider repeat work-up and which labs would you repeat?
This is a difficult question to answer succinctly, as so much information is missing to provide a complete response. However, it does raise some important points that are worth mentioning:There is a prevailing tenet, which I was taught as a resident and hear often from residents today, that 1st epis...