Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What treatment options would you consider for a patient with seronegative inflammatory arthritis in setting of history of liver transplant on mycophenolate mofetil and cyclosporine?
Some of this depends on how far out they are from transplant and the preference of their transplant team. For a patient with RA and a liver transplant, I was able to ask the transplant hepatologist to switch to azathioprine instead of mycophenolate, which was more helpful for the joints. Cyclosporin...
How do you assess the risk of developing demyelinating disease when initiating TNF inhibitors?
Demyelinating disease (DD) associated with TNF inhibitors is rare. Risk assessment is mostly clinical. TNF should be avoided if personal history of established DD specially MS. Strong family history in first degree relatives or concerning neurological symptoms should warrant caution as well; Given t...
How do you approach the treatment of patients with Ehlers-Danlos hypermobile type with chronic muscle spasms with minimal exertion?
You accept that EDS is a genetic connective tissue disorder and not a rheumatological issue. You check hormones and vitamins to ensure they are in range: especially Mg with the cramps. Some EDS patients find working with an EDS physical therapist is beneficial: the goal being to learn how to exercis...
Are there any concerns with live vaccine innoculation and patients who are on denosumab?
This is a complicated question because while denosumab is a biologic therapeutic that has immunomodulatory effects on innate and adaptive immunity its association with serious infections complications appears modest. An increased rate of background infections and some increase in serious infections ...
How do you approach evaluation and management of a patient with recurrent monoarticular inflammatory arthritis of unclear etiology?
Routine testing will not identify Lyme disease, although the WBC count is higher than usual. If the antibiotic does not target B. burgdorferi, recurrence might mean inappropriate therapy previously. WBC count is WAAAY too high for mere trauma or internal derangement. Anything else to suggest psorias...
In a postmenopausal woman who is an avid marathon runner with no prior history of fractures, how would you approach treatment if DEXA shows severe osteoporosis at the distal radius (T-score −4.1) but only osteopenia at the hip and lumbar spine?
I would also make sure there was no error. I had a patient who had similar results, and it was a machine error- the machine was not calibrated correctly.
How do you decide when to discontinue immunotherapy for primary angiitis of the central nervous system (PACNS)?
I take a multidisciplinary approach with involvement of my neurobiology and rheumatology colleagues for the immunotherapy. PACNS can be relapsing or remitting. So needs close monitoring with radiologic (MRI and MRA high resolution vessel wall imaging or CTA/MRA with CSF studies 6 months and then 1 y...
Can you use leflunomide and rituximab in a patient with both multiple sclerosis and rheumatoid arthritis?
It is rare for a patient to have both diseases, but immunosuppressive therapy can be used for the management of both conditions. A study published in 2021 investigated the use of a combination of rituximab and leflunomide in rheumatoid arthritis (Behrens et al., PMID 33738492). Rituximab has previou...
What goes into your decision making when choosing between oral and intravenous bisphosphonate therapies for osteoporosis?
From my perspective if you are going to give a bisphosphonate IV is preferred since it is convenient and there is no risks of GI side effects and issues of compliance. I do not think there is any significant difference in causing ONJ and subtrochanteric femoral fractures. However my preference is De...
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 ...