Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In patients with osteoporosis at high fracture risk, what factors most influence your decision to prescribe teriparatide versus abaloparatide?
Both abaloparatide and teriparatide are very effective anabolic agents to reduce vertebral and nonvertebral fracture risk in patients with osteoporosis (although clinical trials did not demonstrate reduction of hip fracture risk). The two agents are more similar than different and both induce an an...
Do you recommend allopurinol desensitization in gout patients who develop a rash on allopurinol therapy?
I don't recommend desensitization for allopurinol-allergic patients. There was a time when this made sense due to the lack of a viable alternative therapy. The process is cumbersome in a private practice setting and not as simple as providing the patient with a prescription for febuxostat.Febuxostat...
What factors lead you to recommend a JAK inhibitor as second-line therapy in a patient with radiographic axSpA who has had a primary non-response to a TNF inhibitor, before trying an IL-17 inhibitor?
This is an excellent question, which requires not just a treatment plan but also a revelation of how we should be making patient management decisions in Spondyloarthritis (SpA). My initial reaction is that primary non-response to a TNFi is not the usual story; if this truly happens, I recommend re-e...
What is your approach to the diagnostic workup of small fiber neuropathy in patients with known rheumatic disease?
Small fiber sensory neuropathy (SFN), in general, including in patients with rheumatic diseases, should be suspected based on symptoms (positive more than negative sensory symptoms) and ideally confirmed by clinical examination showing altered temperature and/or pain/pinprick perception in the limbs...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
When stopping denosumab and transitioning to PO bisphosphonate, do you wait for 6 months after the last denosumab injection to start PO bisphosphonate?
Some background: In patients discontinuing denosumab without subsequent antiresorptive therapy, BMD rapidly reverts back to baseline with an elevation in vertebral fracture risk (with an enhanced risk of multiple vertebral fractures). Thus, sequential treatment regimens following denosumab have been...
What clinical features would raise your suspicion for IgG-4 related disease?
IgG4-related disease can affect multiple organs, leading to varied presentations. In the abdomen, patients can have symptoms secondary to pancreatitis and or biliary obstruction. In the liver, patients can present with a PSC-like picture (jaundice, cholangitis, ductal strictures/dilatation) that, un...
What therapies have you found most effective for JAK-induced/associated acne (JAKcne)?
Doxy will work quickly and is pretty safe. If all goes well, you can taper the dose of the oral antibiotic and use topical agents.
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 ...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...