Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
How do you interpret treatment response in the DISCOVER-2 Trial when patients were allowed to remain on up to 10mg of prednisone equivalent for disease control while on guselkumab?
The dependence on the use of systemic glucocorticoids may indeed be a good reason to change treatment. Especially in patients with psoriatic arthritis. So, if patients are unable to stop systemic glucocorticoids and there are still treatment options for the patient, this could be tried. It is diffic...
When do you consider genetic testing for autoinflammatory diseases in patients with recurrent pericarditis and fever, particularly when symptoms are highly responsive to IL-1 blockade?
Yesterday ;-). About 10% of patients with recurrent pericarditis have genes that may increase their risk of pericarditis. If you're already managing the patient with IL-1 inhibition, I would strongly encourage you to conduct genetic testing. Just my 2 cents...
Would you offer re-irradiation LDRT for someone with osteoarthritis or tendinitis if symptoms recur?
I have not personally offered a patient a third round of LDRT and do not know of any data that shows efficacy. However, I might offer a third round if a particular patient got adequate results with the first two and there was some separation in time (perhaps >1 year) since the last round.
Do you think the benefits of performing a repeat kidney biopsy to assess histologic evidence of disease activity or chronic damage outweigh the risks in a patient with recently treated lupus nephritis and improving creatinine levels?
In patients with lupus nephritis who have recently undergone treatment and are demonstrating improved creatinine levels, performing a repeat kidney biopsy is generally unnecessary. The risks associated with the procedure do not justify its benefits unless there is persistent or worsening proteinuria...
For those treating osteoarthritis with LDRT, is there any concern of adverse effects or decreased efficacy in patients with osteoporosis?
I’m not aware of any data specifically looking at the efficacy of LDRT for OA in patients with osteoporosis. The anti-inflammatory mechanism of LDRT should not be altered by the bone thickness/quality, but repetitive “injury” contributing to OA may be different if the cause is related to bone qualit...
In the treatment of osteoarthritis with low-dose radiation therapy is there data to support the claim that LDRT does not limit or preclude later orthopedic surgery?
At LDRT doses, the biological effects are anti-inflammatory and immunomodulatory rather than cytotoxic or fibrogenic, and there is no evidence of vascular injury, impaired cellular proliferation, or tissue destruction. Animal models and cellular studies provide robust evidence that LDRT at OA releva...
How do you treat nocturnal leg cramps?
Nocturnal leg cramps are similar to daytime leg cramps, but stretching may be less convenient to use as a remedy, as sleep can be further disrupted. Treating and preventing leg cramps typically utilizes some combination of hydration and electrolytes but sometimes, medications can help. Consider the ...
How long would you recommend that a patient continues guselkumab prior to deciding that the therapy is not effective?
Many trials have a placebo-controlled period of 12-24 weeks. Thereafter, all patients receive active treatment. Even if the original treatment allocation remains unknown to the patient and doctor, they know that from that moment on, everyone receives active treatment. This will have an influence on ...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...