Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What’s your drug of choice for patients with stable antisynthetase NSIP-ILD and overlap RA (CCP+) with significant polyarthritis as main manifestation?
Rituximab
Do you routinely evaluate patients with collagen disorders or Ehlers-Danlos for platelet defects?
Yes, I routinely carry out a full hemostasis evaluation, including platelet aggregation and release studies, in patients referred to me with easy bruising and hypermobility with an increased Beighton score suggesting EDS and in those already diagnosed genetically with EDS. EDS patients typically hav...
Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?
The landscape of FUO and IUO and our clinical approach to diagnosing its cause has changed significantly over the past several decades. More sensitive microbiologic screening for infectious etiologies, including syndromic molecular panels and next-generation sequencing are now clinically available a...
How do you manage patients with scleroderma who present with finger ulcerations without other signs of soft tissue infection and MRI demonstrates potential concern for osteomyelitis?
I use Mupirocin ointment which help prevent infection and seems to assist in healing.
Do you recommend patients hold folic acid on the day they take methotrexate?
The proposed mechanism of action (MOA) of methotrexate in rheumatic disease is not from the antimetabolite angle (given its oncologic MOA as a dihydrofolic acid reductase inhibitor), but rather as a potent anti-inflammatory and immunomodulatory medication through the MOA of extracellular adenosine a...
What is your approach to counseling patients on the safety and side-effect profile of a biosimilar compared to its reference biologic?
Relevant question as insurance companies may require a biosimilar over the reference biologic. According to the FDA, the spin-off (my term) must be "highly similar" to the original in both efficacy and safety. Approval is based on review of clinical trial data. As for my approach: until proven other...
In what clinical situations would you favor IM methylprednisolone over a short oral prednisone taper for managing an RA flare?
I am not an RA expert; however, I am well-versed in the use of IM steroids for flares.After Dr. Petri's FLOAT study in SLE (Danowski et al., PMID 16395750), we have utilized IM steroids instead of daily PO prednisone as our "go-to" treatment of choice as much as we can over Medrol dose packs and QD ...
How would you approach managing an asymptomatic patient with normal kidney function who has elevated p-ANCA and MPO titers along with evidence for pauci-immune glomerulonephritis on kidney biopsy?
I would assume the patient has hematuria and proteinuria, and that is why they had a kidney biopsy. I would treat this patient with immunosuppression, but would be willing to reduce the dose and duration of immunosuppression depending on the response of the patient. Following the ANCA titer would al...
How would you approach the evaluation and management of a patient with rheumatoid arthritis receiving leflunomide who presents with progressive peripheral pulmonary cavitary nodules, with biopsy revealing necrotizing granulomatous inflammation?
Given the association between leflunomide and nodules with necrosis and giant cells (though quite rare), I would consider stopping leflunomide and moving to another agent. I would, of course, make sure that cultures are negative on those nodules, given it could be mycobacterial, fungal, or even GPA.
How would you approach immunosuppression in a patient with well-controlled HIV and RF+ rheumatoid arthritis breaking through hydroxychloroquine with ongoing inflammation confirmed on ultrasound?
There is a reasonable amount of literature on this topic. The consensus is that if ongoing HAART therapy is effective at controlling viral load and maintained, Methotrexate and TNF antagonists are well tolerated; they do not seem to affect HIV viral load. The safety of JAK inhibitors, leflunomide, a...