Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Here is a recent expert consensus by Joel Block on the use of low-dose radiation therapy in OA: Some highlights: "Placebo-controlled randomized clinical trials have now been reported using LDRT for OA of the knees and of the hands. Taken together, they do not show benefit beyond placebo... While a d...
What are your practice recommendations regarding live vaccinations in infants/children of women who are currently on DMARDs and are breastfeeding?
This question needs some clarification to provide an exact answer. However, in regards to DMARDs in lactation, per the ACR 2020 Reproductive Health Guidelines and resources like LactMed and Mother to Baby (both free!), Methotrexate, Leflunomide, and Mycophenolate are not recommended in lactation. Th...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
How has the ADVISE trial changed your approach to steroid sparing agents for non-infectious uveitis?
The ADVISE trial was a well-designed, multinational trial that compared adalimumab therapy for non-infectious intermediate, posterior, or panuveitis versus conventional immunosuppressive therapy or CID. Two hundred twenty-seven subjects were enrolled over four years, and a fifth year was required to...
Would you start urate lowering therapy in a patient with recurrent flares of joint pain/swelling and urate deposition confirmed by dual energy CT, despite a serum uric acid of 5 mg/dL between flares?
Of course, with colchicine or NSAID co-prescription, but first examine dietary excesses and medication effects, which can produce flares.
Can sIL2-R differentiate between active sarcoidosis affecting small airways vs uncontrolled asthma and guide treatment with methotrexte vs biologics?
Not exactly, and probably not with enough compelling precision to use it clinically. sIL-2R cannot reliably differentiate active small-airway sarcoidosis from uncontrolled asthma, nor can it independently select methotrexate versus biologic therapy. It is a marker of systemic T-lymphocyte/granuloma ...
How do you approach management autoimmune lymphoproliferative syndrome (ALPS) complicated by HLH?
Excellent and tough question. There are no direct guidelines for this specific question. We will have to extrapolate from other evidence and clinical reasoning.Investigation of the trigger must occur in parallel with management. I will discuss how I approach investigation first and then management.I...
What strategies have you found most helpful to improve adherence to hydroxychloroquine among patients with lupus?
In my practice, three approaches have been most useful: Make adherence measurable. I routinely check whole-blood hydroxychloroquine levels and review the trend with patients in a nonjudgmental way. This creates accountability and turns an otherwise “invisible” treatment into something concrete that ...
For patients with patellofemoral pain syndrome whose symptoms continue despite an adequate course of physical therapy, what adjunctive treatments (bracing, taping, injections, orthotics, or imaging) do you consider most helpful?
After an adequate course of physical therapy (under the guidance of a knowledgeable PT), I recommend imaging to determine if there is underlying pathology like chondromalacia, chondrosis/fissuring, an OCD lesion, or perhaps a tendinopathy or fat pad impingement. Starting with a plain film (AP, later...
How often do you draw screening ANAs for discoid lupus?
Because a positive ANA is associated with an increased risk of progression to SLE in patients with discoid lupus, I routinely check an ANA at the initial visit in virtually all patients. If negative, I repeat it only if new symptoms concerning systemic involvement arise (e.g., joint pain, cytopenias...