Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
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 ...
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...
How do you approach the management of inflammatory arthritis in a patient with Sjogren’s disease who is unable to tolerate or take methotrexate, leflunomide, or hydroxychloroquine?
Would consider a B-cell targeted agent. Currently, rituximab, which was included in the 2017 MSK and biologic guidelines (Carsons et al. AC&R PMID: 27390247) for SjD inflammatory arthritis.Serum level of BAFF is elevated in SjD, so an anti-BAFF agent, like belimumab, could be considered.Have avoided...
In what clinical situations would you favor IM methylprednisolone over a short oral prednisone taper for managing an RA flare?
Oral prednisone is a pro-drug - it needs to be activated by the liver into prednisolone to work. In addition, if the patient is challenged by GI absorption or has significantly low serum albumin, this reduces the effect of oral prednisone. Those situations would be my greatest concern for such a cho...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
Do you prioritize aerobic exercise over pharmacotherapy as the first active intervention in a patient with newly diagnosed fibromyalgia who has no prior treatment?
I use both in parallel as first-line agents. No one will improve if they're not moving (I use the word "movement" or "activity," rather than "exercise," as this could sound excessive to some folks). I only avoid pharmacotherapy if the pt. feels strongly against taking medications, but most people ar...
Would you give a trial of immunosuppression in a patient with previously diagnosed IPF who now comes to you with moderate titer ANA and history of discoid lupus but no other clear systemic features or lab abnormalities suggestive of SLE?
No, I would not automatically RX immunosuppressants in this clinical scenario, which has numerous facets to it that do need to be addressed: The treatment for progressive idiopathic pulmonary fibrosis (IPF) is an antifibrotic, not an immunosuppressant. I ALWAYS manage my SLE-pulmonary patients with ...
How long after stopping prednisone do ESR and CRP become clinically reliable for reassessing disease activity?
As with most issues related to corticosteroids, the dose and duration of use matter. When steroids have been tapered slowly after a lengthy period of use, e.g., patients with PMR, it may take weeks (at the least) until we get a true reading of their ESR and CRP values. For shorter tapers, such as fo...
How do you optimize retinopathy screening schedules for patients on hydroxychloroquine while also prioritizing cost-effectiveness?
I'll approach this from the cost-effectiveness standpoint as I agree with Drs. @Dr. First Last and @Dr. First Last on their excellent points.Patients with SLE have remarkably high costs when you add up copays, medications, imaging studies, travel, missing work, etc. Anything we can do to help reduce...