Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you reduce the dose of hydroxychloroquine in patients with skin graying if they are not particularly bothered by this side effect?
I wouldn't if they're not bothered, but I would think to look into their HCQ blood levels... we know that certain doses of HCQ are more effective in controlling disease activity than others, and that of course, higher levels may be associated with adverse effects, not just in the skin.
How would you counsel a woman with a strong family history of thrombosis about oral contraceptives?
This can be a complex question for which there are likely no specific data or guidelines upon which to base a recommendation. ASH has published guidelines on thrombophilia testing in VTE (Middeldorp et al., PMID 37195076). They specifically recommend against testing prior to COC prescription. The ra...
How do you optimize retinopathy screening schedules for patients on hydroxychloroquine while also prioritizing cost-effectiveness?
I'll approach this from the cost-effectiveness standpoint as I agree with Drs. @Dr. First Last and @Dr. First Last on their excellent points.Patients with SLE have remarkably high costs when you add up copays, medications, imaging studies, travel, missing work, etc. Anything we can do to help reduce...
If methotrexate is contraindicated or not tolerated, what systemic treatments do you use for generalized morphea?
I typically reach for mycophenolate as a second-line agent if methotrexate failed or is contraindicated. If the generalized morphea is actively progressing, I will add a steroid taper as a bridge until the DMARD has time to take effect. Whole body UVA1 is also a helpful adjunctive treatment to a DMA...
How do you approach screening for ILD in patients with a diagnosis of MCTD given the recommendation discrepancies between the most recent EULAR and ACR/CHEST guidelines?
Another excellent question! While the EULAR guidelines treat MCTD as SSc-equivalent and suggest universal screening, ACR/CHEST guidelines suggest risk-stratified screening with emphasis on symptoms, PFT abnormalities, and high-risk phenotypes.Prevalence of ILD in MCTD can be high, in the range of 30...
Would you favor the use of denosumab over bisphosphonate therapy for treatment of osteoporosis in patients who are at high risk for osteoarthritis given recent data suggesting reduced risk of developing knee OA?
Although the overall data to date concerning the impact of denosumab to reduce incident knee OA or lessen established disease remain limited, there are sufficient signals that warrant further investigation and support the need for an appropriately powered RCT with endpoints that include both patient...
How do you approach the management of autonomic neuropathy in a patient with Sjogren's?
Early on in working with autoimmune patients, I had access to neurogastroenterology specialists and gained an appreciation for GI dysmotility disorders. In addition to Scleroderma, Sjogren's patients frequently had documented abnormalities on motility studies. Neuro and immune abnormalities can lead...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.