Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
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...
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...
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.