Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you treat tophaceous gout after a course of pegloticase infusions if the patient has contraindications or intolerance to allopurinol, febuxostat, and probenecid?
Difficult question. I think there are a number of issues to address. What is a "course of pegloticase?" What are the patient's contraindications to treatment? How did intolerance to prior oral uric acid-lowering therapies manifest Was pegltoicase started because of "unresponsiveness to oral ULT" an...
How do you assess and manage cavitating pulmonary rheumatoid nodules?
Challenging and rare situation these days!So first, my goal is to confirm that these cavitary nodules are indeed rheumatoid nodules, meaning that there is minimal concern for malignancy, infection, or an alternative cause.There’s a study from Mayo that aims to help differentiate rheumatoid nodules a...
In the setting of new onset severe Raynaud’s with digital ischemia (partial toe amputation), but negative initial rheumatologic evaluation, what additional rheumatologic or hematologic workup should be considered?
This is always a difficult situation. As Rheumatologists, we tend to lean hard on the laboratories, but in cases like this, it is the history and physical examination that tell the better story. The history is critical here, since a smoking/tobacco history gives a lot of information. Any history of ...
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.
In patients with Sjogren’s disease, what is your approach to baseline ILD screening and subsequent monitoring?
My approach generally follows the Consensus Guidelines for Evaluation and Management of Pulmonary Disease in Sjögren’s published in Chest in 2021 (Lee et al., PMID 33075377). These guidelines specify different approaches for asymptomatic patients diagnosed with SjD versus SjD patients with pulmonary...
Should we be less cautious with the use of GLP 1 R agonist therapy for patients with osteoporosis and obesity given recent data suggesting significantly lower fall and fracture risk?
The interaction of GLP-1 R agonist therapy and fracture risk is complicated, and I would not assume a decrease in the risk of fracture for most patients. However, there were three recent retrospective studies that all showed decreased fracture risk following use of either semaglutide or tirzepatide ...
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...
Under what circumstances would you consider low-dose radiation therapy for osteoarthritis in an older adult patient?
Here is a recent expert consensus by Joel Block on the use of low-dose radiation therapy in OA: Some highlights: "Placebo-controlled randomized clinical trials have now been reported using LDRT for OA of the knees and of the hands. Taken together, they do not show benefit beyond placebo... While a d...
In the treatment of osteoarthritis with low-dose radiation therapy is there data to support the claim that LDRT does not limit or preclude later orthopedic surgery?
At LDRT doses, the biological effects are anti-inflammatory and immunomodulatory rather than cytotoxic or fibrogenic, and there is no evidence of vascular injury, impaired cellular proliferation, or tissue destruction. Animal models and cellular studies provide robust evidence that LDRT at OA releva...
As a primary care provider, how do I reconcile the different types of immunosuppression? I realize that solid organ transplant immunosuppression is much more intense and riskier compared to medications like Humira or Dupixent, or an undetectable viral load in HIV. How do these differences affect cervical cancer screening?
Dr. @Dr. First Last, I like this question a lot. We rheumatologists can tend to forget how complicated this topic can be.I. Hydroxychloroquine (Plaquenil), the #1 drug to treat SLE, is often mistaken as an immunosuppressant, but it is not. It is an immunomodulatory therapy without true immunosuppres...