Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What specific criteria or patient conditions would make you hesitant to use fluoroquinolones early in the treatment course for managing MSSA joint infections with oral antibiotics?
For MSSA joint infections, I have moved away from using FQ to using high-dose cephalosporins as a step-down therapy, particularly cefadroxil 1 g twice daily, given less frequent dosing/increased adherence. Considering the risk-benefit analysis, I prefer using FQ as an oral option in polymicrobial an...
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...
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?
The hand pain is likely mechanical in origin. Daily activities need to be reviewed and joint protection methodology pursued. Collaboration with an occupational therapist is critical. And, wean off the steroids.
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 ...
Are there any concerns with live vaccine innoculation and patients who are on denosumab?
This is a complicated question because while denosumab is a biologic therapeutic that has immunomodulatory effects on innate and adaptive immunity its association with serious infections complications appears modest. An increased rate of background infections and some increase in serious infections ...
Do you have safety concerns when prescribing GLP-1 medications in patients on corticosteroids or immunosuppressive therapy?
I think we need to be particularly careful when co-prescribing with systemic corticosteroids because of the risk of sarcopenia. We know that rapid weight loss is accompanied not only by a loss of fat tissue but also of muscle. Corticosteroids can also have myotoxicity and cause muscle atrophy. I the...
When do you prefer bariatric surgery such as sleeve gastrectomy or gastric bypass over an initial trial of a GLP-1 receptor agonist in patients with severe obesity and painful knee or hip osteoarthritis?
I believe that this type of decision should be made by obesity specialists and not by rheumatologists. However, we can anticipate that the patient's choice is paramount: some prefer radical options such as surgery, while others cannot bear to hear about it. The decision should only be made through d...
Do you prioritize aerobic exercise over pharmacotherapy as the first active intervention in a patient with newly diagnosed fibromyalgia who has no prior treatment?
I use both in parallel as first-line agents. No one will improve if they're not moving (I use the word "movement" or "activity," rather than "exercise," as this could sound excessive to some folks). I only avoid pharmacotherapy if the pt. feels strongly against taking medications, but most people ar...
How would you work up a patient with cutaneous mastocytosis?
Is a BM biopsy a must when there is skin involvement? I think a bone marrow biopsy for cutaneous mastocytosis is most helpful when it is in the setting of a patient being referred by dermatology for a skin biopsy result showing TMEP (telangiectasia macularis eruptive perstans) since TMEP has been ...
How do you approach the management of inflammatory arthritis in a patient with Sjogren’s disease who is unable to tolerate or take methotrexate, leflunomide, or hydroxychloroquine?
Would consider a B-cell targeted agent. Currently, rituximab which was included in the 2017 MSK and biologic guidelines (Carsons et al., PMID 27390247) for SjD inflammatory arthritis.Serum level of BAFF is elevated in SjD, so an anti-BAFF agent, like belimumab, could be considered.Have avoided use o...