Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you recommend structured Tai Chi for patients with osteopenia and osteoporosis?
While I am not an expert, I am very supportive of Tai Chi or similar disciplines that work to improve balance. I have read some well done clinical trials that show improved balance. I live in a community (Phoenix) with lots of active retired people. Nearly every community has a Tai Chi or balance cl...
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.
How do you approach the management of recurrent episcleritis in a patient with RA that is otherwise well-controlled?
The episclera lies on top of the sclera. The majority of patients with episcleritis do not have a systemic disease, although patients with rheumatoid arthritis are more prone to develop episcleritis. Episcleritis must be distinguished from scleritis, which is also associated with rheumatoid arthrit...
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 medication-related osteonecrosis of the jaw (MRONJ) and significantly high fracture risk from osteoporosis, prior history of osteonecrosis is not considered an absolute contraindication for bisphosphonate use. The clinical picture is important in weighing this decision. If the p...
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 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 ...
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.
Do you generally pursue a temporal artery biopsy in a patient who has a halo sign on ultrasound but has an atypical clinical presentation of GCA with normal inflammatory markers in the setting of persistent temporal headache?
This is an important question, and the answer would depend significantly on the details of the presentation. In general, with a highly atypical presentation such as this with normal inflammatory markers AND atypical symptoms, I would pursue TA biopsy and consider large vessel imaging if negative. Wh...
Do you generally utilize calcium channel blockers on an as needed basis for patients with Raynaud's phenomenon?
Can certainly help when patients have conditions that trigger Raynaud's. If otherwise healthy, I discuss keeping the extremities protected from excessive cooling.
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...