Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you counsel patients on the potential benefits of nerandomilast for PPF?
I would frame the benefit as preservation rather than improvement. The goal is to slow the additional loss of lung function over time.In FIBRONEER-ILD, patients receiving placebo lost about 166 mL FVC over a year, compared with 99 mL on nerandomilast 18 mg and 85 mL with 9 mg. This translated into a...
Do you expect a different response rate to neradomilast depending on the ILD phenotype?
As a rheumatologist, I am particularly interested in the autoimmune ILD subtype and reviewed with great interest the subgroup analysis published in the Annals of Rheumatic Diseases by Anna-Maria Hoffman-Vold et al., PMID 42062162, which reports specifically on the 324 patients with autoimmune ILDs (...
How do you manage patients with severe hand OA (no synovitis on exam, negative serologies) who fail to respond to NSAIDs but respond very well to oral steroids?
I have used Hydroxychloroquine with some success and offer that to patients for a trial for 4 months if they are willing.
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 ...
What additional workup and steroid-sparing option would you choose in a patient with potential medium-vessel vasculitis (petechial rash, sensorimotor neuropathy, renal infarcts, renal artery micro-aneurysms and ischemic/ulcerative duodenitis), hypocomplementemia, ASO 1525, negative blood cultures and normal echo?
This is a challenging case. Generally, PAN should be confirmed histologically, particularly if there are atypical features. In this case, hypocomplementemia is atypical, as non-HBV-associated PAN is generally normocomplementemic. Further, PAN more commonly causes ulcers/nodules/reticular lesions tha...
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 ...
In a patient with sicca symptoms and SS-B antibodies only, can a minor salivary gland lip biopsy with lymphoid aggregates, but also scattered areas of acute neutrophilic inflammation be consistent with Sjogren's Disease?
I agree with @Dr. First Last and cannot speculate on the neutrophils.I'd also like to point out that a French study showed that only 1% of isolated anti-SSB patients had Sjogren's disease, SjD (Jardel et al., PMID 28931060); all others had other autoimmune diseases, neoplasia, infection, and solitar...
How would you approach a patient referred for esophageal aperistalsis with a longstanding history of Raynaud’s phenomenon, but without other clinical features or serologic findings suggestive of systemic sclerosis?
Scleroderma esophagus (distal aperistalsis/absent contractility + hypotensive LES) is a manometric finding, not a diagnosis. There are multiple causes of this finding, including other autoimmune diseases, neuropathic conditions, and metabolic causes.In addition, RP is seen in 3-8% of the population....
Does significant eosinophilia (8-44%) in a patient with suspected granulomatosis with polyangiitis (GPA) based on sinusitis, pulmonary nodules and positive PR3 change your management approach?
This is an important question because at times the distinction between GPA and EGPA can be difficult to make. In general, I would rely on clinical symptoms as a key distinguisher. For example, sinusitis in GPA differs from that of EGPA, with the former often causing crusting, erosions/necrosis on EN...
What is your approach to management of patients with recurrent nephrolithiasis and osteoporosis who are receiving teriparatide?
Bones and calcium containing kidney stones can interact. I find it interesting that patients who have primary hyperparathyroidism are prone to predominantly calcium phosphate kidney stones, since the action of parathyroid hormone on renal tubes is to reabsorb urine calcium. That’s why people with hy...