Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What are the current recommendations for the management of pediatric non-infectious uveitis?
Agree with Dr. @Dr. First Last's answer. By the time these patients see pediatric rheumatology, they have had a number of labs drawn looking for infectious and non-infectious etiologies of uveitis and have also usually been trialed on topical steroid drops (predforte or otherwise) +/- oral prednison...
When using IV TNF inhibitors, do you follow levels to determine if the current dose is adequately treating the patient?
I tend not to get levels, but rather I rely on clinical response; if partial response, often increasing dose (or shorten intervals) can provide dramatic benefit. If the prior response is lost, then consider getting levels and checking for HACAs. I often use TNFi with csDMARDs (e.g., weekly SC methot...
For a pediatric patient with juvenile spondyloarthropathy with partial response, though ongoing axial disease, on a JAKi, would you increase the dose of JAKi, add methotrexate, or switch to alternate therapy like IL-17 inhibition?
Let me first disclose that I am not a pediatric rheumatologist and would defer to one. Have NSAIDs been tried and optimized? If not, that is the best first option. In general, optimizing the dose of a medication that seems to be working is a great choice. However, I do not know what current dosage i...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
Consideration of risk factors is important. Routinely, someone without these risk factors, and if getting a short burst of steroids, the GI prophylaxis is not given. PPIs carry certain risks, including increased risk of C. Diff infection or even pneumonia. So, they should be avoided if not indicated...
How do you approach management of a patient presenting with clinical manifestations of systemic sclerosis (cutaneous involvement, Raynaud’s phenomenon, and pulmonary arterial hypertension) but negative serologies?
Systemic sclerosis is a clinical diagnosis, and there are patients who don't demonstrate antibodies on currently available clinical labs. In addition, there are patients with mild phenotypes who may also not meet the current classification criteria. I think if the clinical syndrome is consistent wit...
What is your approach to a patient with generalized morphea, no systemic involvement but a positive RNA Polymerase III?
I would perform age-appropriate cancer screening given the link between RNA pol III and cancer. Otherwise, I would simply monitor for onset of systemic sclerosis or other autoimmune disease symptoms.
How do you clinically and diagnostically distinguish stiff skin syndrome from scleroderma?
They are distinct conditions, with scleroderma primarily manifesting as skin thickness, fibrosis, and Raynaud's, while stiff person syndrome is a neurological condition manifesting as rigidity and with muscle spasms. The latter serologically has anti-GAD antibodies, compared to scleroderma, which ha...
How do you approach an isolated positive anti-Scl-70 antibody in a patient with no symptoms or exam findings suggestive of systemic sclerosis?
We see this often in the clinic, and it is usually a false-positive test. False-positive anti-topoisomerase I (Scl-70) results frequently occur with commercial immunoassays (ELISA/Multiplex), often leading to misdiagnosis of systemic sclerosis. In our practice, we repeat the test using immunodiffusi...
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...
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...