Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What do you include in differential diagnosis when evaluating a patient with calcinosis cutis?
When evaluating the patient with calcinosis cutis, I first make sure that the patient indeed has calcinosis cutis.In general, there are two types of ectopic calcifications in soft tissues, metastatic and ectopic. Metastatic calcifications occur in the setting of abnormal. serum calcium and or phosph...
Do you obtain mycophenolate levels before escalating therapy in patients with extrarenal SLE?
Similar to Dr. @Dr. First Last, I primarily check MPA levels to assess adherence to therapy. Not surprisingly, poor adherence is common due to the high pill burden of taking mycophenolic acid analogs (MPAA). Finding an unexpectedly low level can open that conversation about identifying barriers and ...
How would you manage a patient with symptomatic Paget’s disease and osteoporosis who developed new fragility fractures while on Fosamax?
This is a complicated patient, and symptomatic Paget's needs more information. But given one wants to treat the Paget's and there are fragility fractures I would give an injection of Zoledronic Acid (mostly for the Paget's) and if needed, start Romosozumab for the fragility fractures. However, I wou...
What treatment options do you consider after TNF failure in intestinal Behcet's with ongoing steroid dependence?
I like apremilast for joint manifestations; but for intestinal BD, I’d prefer tacrolimus.
How long do you maintain patients with anti-synthetase syndrome on Rituximab?
This is a challenging question to address, as there are no evidence-based guidelines, and multiple approaches may be attempted. My practice is that once the patient has been stable for at least 6–12 months, and after discussing the risk of flare with them, I attempt to reduce immunosuppression. For ...
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 ...
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 any role for administering another course of recombinant zoster vaccine (Shingrix) in a previously vaccinated patient with RA, who is in clinical remission on JAK inhibitor but has had a breakthrough shingles infection?
Dr. @Dr. First Last has provided a very complete and literate response. However, the critical word is “likely”. As with most vaccines, both the strength and the duration of response to the zoster vaccine decline with worsening levels of immunosuppression. We have increasingly adopted the practice of...
Was the methotrexate dose reduced over time in the combination therapy or methotrexate monotherapy groups in the SEAM-RA trial?
No, methotrexate dose was not adjusted. Our goal was basically to answer one question: whether it is better to stop etanercept, stop methotrexate, or continue both. We did not want to be adjusting methotrexate doses at the same time as stopping because this would make results more difficult to inter...
Can sIL2-R differentiate between active sarcoidosis affecting small airways vs uncontrolled asthma and guide treatment with methotrexte vs biologics?
This is an interesting question. Just to provide a little context, I used to have a sarcoidosis-focused clinic where one day each week I would see only sarcoidosis patients. I also had a day of seeing only neurosarcoidosis patients once per month, together with neuroimmunology. To be honest, since I...