Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In patients with connective tissue disease-associated interstitial lung disease (CTD-ILD) who have achieved clinical and physiologic stability after successful discontinuation of prednisone while on mycophenolate mofetil, how do you typically approach tapering or discontinuing the mycophenolate?
Unfortunately, there are no high-quality, evidence-based guidelines that specifically address tapering or discontinuing mycophenolate mofetil (MMF) in CTD-ILD after achieving clinical stability. The available literature strongly favors prolonged maintenance therapy rather than early discontinuation,...
What is your approach to refractory oral ulcers in SLE?
Would not consider only trying HCQ as being refractory. Many more lupus medications to be tried! Azathioprine, MMF, Methotrexate, and Benlysta would all be under consideration. I presume their labs show some aspect of active SLE.
What strategies have you found most helpful to improve adherence to hydroxychloroquine among patients with lupus?
In my practice, three approaches have been most useful: Make adherence measurable. I routinely check whole-blood hydroxychloroquine levels and review the trend with patients in a nonjudgmental way. This creates accountability and turns an otherwise “invisible” treatment into something concrete that ...
Should special precautions be taken patients with Ehlers-Danlos syndrome receiving radiation therapy?
Not all EDS is the same. Most commonly, an EDS patient these days is a clinically diagnosed patient with hypermobile joints, possibly stretchy skin, and possibly chronic pain syndrome. That is a very different picture from vascular EDS with a COL3A1 mutation, which is rare and would have the extreme...
In a patient with persistent symptoms of Lyme arthritis after initial treatment course with oral antibiotics, do you prefer a second course of oral antibiotics or do you frequently offer a course of IV ceftriaxone?
Patients diagnosed with Lyme arthritis should receive a 28-day course of oral antibiotics, preferably doxycycline. If patients achieve at least a partial response, a second course of oral antibiotics may be given. However, in patients with minimal to no response following the initial course of oral ...
Have you utilized denosumab in treatment of erosive hand osteoarthritis?
I have not prescribed denosumab for patients with erosive hand osteoarthritis. While the 2024 double-blind placebo-controlled trial suggested that this RANK ligand inhibitor may have structure-modifying effects by inducing remodeling and preventing new erosions, the phase 2a study of 100 patients di...
How do you approach laboratory evaluation in patients with fatigue?
First search for evidence by history and physical examination for any evidence of inflammation. If there is tailor the lab workup rather than ordering tests as screening tools. ESR and CRP to start with. Anything more without a reasonable a priori likelihood of the targeted diagnosis is just asking ...
How do you counsel patients with GCA on the benefits of steroids who have already experienced vision loss?
I first tell the patient they are at considerable risk for further visual loss in the same eye or the other eye over the next 1-2 weeks. I also let them know that, even though their risk of visual loss has been reduced, their best option for preventing further visual loss is immediately starting hig...
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?
The dependence on the use of systemic glucocorticoids may indeed be a good reason to change treatment. Especially in patients with psoriatic arthritis. So, if patients are unable to stop systemic glucocorticoids and there are still treatment options for the patient, this could be tried. It is diffic...
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 ...