Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Can you use bisphosphonates in a patient with osteoporosis who has had prior avascular necrosis of TMJ due to steroid use?
Due to the rarity of MRONJ, and significantly high fracture risk from osteoporosis, prior history of osteonecrosis is not considered an absolute contraindication for bisphosphonate use. Clinical picture is important is weighing this decision. If the patient is very high risk, anabolic therapy is app...
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-ev...
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?
If patients were on less than or equal to prednisone 10 mg, they could continue that in the background during the trial, but note that only 20% of patients were on prednisone, a much lower figure than a typical rheumatoid arthritis trial, which is consistent with the point that rheumatologists shy a...
Is there any role for immunosuppressive therapy in patients with primary Sjogren's disease with severe pulmonary artery hypertension without ILD findings?
PAH (WHO Class I PH) in/and SJD is not a common relation, and as such would Rx as we Rx regarding PAH in PSS? The pathophysiology of PSS is, at least in part, a vasculopathy that SJD may not share. The question is, however, specific regarding Primary SJD and the assumption then is that this is not a...
How often are you performing CT screening in CVID patients to screen for ILD?
CT once every 1-2 years, depending on symptoms and PFTs. PFTs, including DLCO, are annually performed.
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
Does SI joint erosion on MRI pelvis push you to use TNF inhibitors over NSAIDs as first line for axial spondyloarthritis?
A decision to consider TNFi (or another targeted therapy) over initial NSAID therapy depends primarily on disease severity, symptom burden, and impact on quality of life, presence of significant peripheral disease (where csDMARDs have already failed or resulted in side effects), contraindications or...
Do you routinely apply the 2010/2011 ACR symptom-based diagnostic criteria for fibromyalgia in your practice, or do you continue to use the 1990 tender point examination to make the diagnosis?
Fibromyalgia diagnostic criteria have been a source of controversy and multiple revisions. Much of this confusion relates to failing to distinguish classification criteria, established to provide uniform criteria for clinical studies, from diagnostic criteria, which rely on expert opinion. Rheumatol...
For a patient with suspected post-streptococcal reactive arthritis who does not meet criteria for acute rheumatic fever and has a normal echocardiogram at presentation, do you prescribe 1 year of antibiotic prophylaxis?
This is a loaded question. Post-Streptococcal reactive arthritis (PSRA) plagued me during my fellowship (many moons ago). There is a fine line between PSRA and rheumatic fever (RF). We rarely see RF in the United States anymore. If I'm convinced it is PSRA and not RF (e.g., RF migratory arthritis qu...
In patients with a history of retinal vein occlusion, how should the risk of recurrent thromboembolic events influence the selection of osteoporosis therapies?
The FDA-approved prescribing information for raloxifene explicitly lists retinal vein thrombosis alongside deep vein thrombosis and pulmonary embolism as contraindications.