Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you manage patients with scleroderma who present with finger ulcerations without other signs of soft tissue infection and MRI demonstrates potential concern for osteomyelitis?
I use Mupirocin ointment which help prevent infection and seems to assist in healing.
Do you recommend patients hold folic acid on the day they take methotrexate?
The proposed mechanism of action (MOA) of methotrexate in rheumatic disease is not from the antimetabolite angle (given its oncologic MOA as a dihydrofolic acid reductase inhibitor), but rather as a potent anti-inflammatory and immunomodulatory medication through the MOA of extracellular adenosine a...
What is your approach to counseling patients on the safety and side-effect profile of a biosimilar compared to its reference biologic?
Relevant question as insurance companies may require a biosimilar over the reference biologic. According to the FDA, the spin-off (my term) must be "highly similar" to the original in both efficacy and safety. Approval is based on review of clinical trial data. As for my approach: until proven other...
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 ...
How would you approach managing an asymptomatic patient with normal kidney function who has elevated p-ANCA and MPO titers along with evidence for pauci-immune glomerulonephritis on kidney biopsy?
I would assume the patient has hematuria and proteinuria, and that is why they had a kidney biopsy. I would treat this patient with immunosuppression, but would be willing to reduce the dose and duration of immunosuppression depending on the response of the patient. Following the ANCA titer would al...
How would you approach the evaluation and management of a patient with rheumatoid arthritis receiving leflunomide who presents with progressive peripheral pulmonary cavitary nodules, with biopsy revealing necrotizing granulomatous inflammation?
Given the association between leflunomide and nodules with necrosis and giant cells (though quite rare), I would consider stopping leflunomide and moving to another agent. I would, of course, make sure that cultures are negative on those nodules, given it could be mycobacterial, fungal, or even GPA.
How would you approach immunosuppression in a patient with well-controlled HIV and RF+ rheumatoid arthritis breaking through hydroxychloroquine with ongoing inflammation confirmed on ultrasound?
There is a reasonable amount of literature on this topic. The consensus is that if ongoing HAART therapy is effective at controlling viral load and maintained, Methotrexate and TNF antagonists are well tolerated; they do not seem to affect HIV viral load. The safety of JAK inhibitors, leflunomide, a...
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...
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...
What is your approach to nephrology referral for patients with lupus nephritis?
The answer to this question "depends" on many factors.I had the luxury of learning under some lupus nephritis greats in the 1990s (John "Jack" Klippel, H Austin, and J Balow... the high-dose NIH CYC regimen guys). Therefore, I am fortunate to feel confident in my abilities to care for LN better than...