Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
What would be your recommendation for treatment of worsening lung disease in a patient with long-standing scleroderma after long-term mycophenolate therapy which is no longer an option due to side effect/intolerance?
Someone who has been on long-term Mycophenolate for interstitial lung disease and has had stabilization or improvement in their lung function and then is unable to tolerate the medication may be able to be switched to mycophenolic acid sodium (myfortic) which is often less toxic and better able to b...
How often are you repeating screening PFTs in patients with SARDs who have 3 or more years of normal or stable PFTs?
The answer to this question is complex and needs to be tailored to the individual patient’s risk for ILD and the particular SARD.Approximately 30-40% of patients with systemic sclerosis (SSc) will develop ILD, typically within the first 5 years after the first non-Raynaud’s manifestation and rarely ...
Where in the sequence of biologics would you consider guselkumab for patients with active psoriatic arthritis despite standard DMARD therapy?
This is an extremely important question and one that is likely to change as new data becomes available. It is important to remember that psoriatic arthritis (PsA) is a complex and heterogeneous disease and a single approach does not work for every patient. Based on the ACR/NPF 2019 PsA treatment gui...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
How will you approach tapering of therapy in a patient with PsA who has responded well to tirzepatide and ixekizumab and has maintained disease remission for several years?
This is a difficult question to answer based on current data. While tapering is a standard strategy for DMARD therapies in many rheumatic diseases, many studies show that successful tapering or therapy discontinuation is not possible for most patients. If we are evaluating ixekizumab alone, few pati...
How do you counsel patients who ask if there are any dietary modifications they can make to help control their autoimmune disease?
I send patients to a website called nutritionfacts.org. This is a non-profit website that reviews medical literature related to nutrition and diseases. It was founded by Dr. Greger and he is not trying to sell anything which I appreciate. He has bite-sized videos on anything you can think about rela...
Would you stop methotrexate or leflunomide if MCV increases after starting the medication with no other parameters of anemia or leukopenia?
I would take this as a sign that the patient is taking their medication. Pretty common and definitely wouldn’t withhold RA tx for this.
Is there a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients?
There is no good-quality evidence supporting a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients. The efficacy of nitazoxanide in viral gastroenteritis is supported by a small manufacturer-sponsored randomized, double-blind trial in non-immunocompromised ...
In patients with livedoid vasculitis and chronic venous insufficiency on rivaroxaban, what therapeutic strategies—beyond compression and topical care—are safe and effective for controlling pain, ulceration, and edema?
My experience has been that aspirin 365 mg, plus persantine or trental daily, plus leg elevation for 45 min or so in mid-afternoon, will produce pain relief and onset of healing within about two weeks. Only infrequently have I had to resort to metformin as an added medication or use both trental and...