QD clinics - lessons from the Clinic brought to you by RheumNow Live 2025 Save

Welcome back to QD Clinic. We've been away for a while. QD Clinic is brought to you by RheumNow Live twenty twenty five, February eighth and ninth. Great faculty, shorter lectures, more discussion. This is where knowledge meets practice.

We hope to see you there. Today's case begs the question, is it crest or is it diffuse disease? A 49 year old white male presents with tightness and joint pain, tightness in his fingers. And at the outset, in early twenty twenty two, he had some shortness of breath, Came in to see me. He had significant Raynaud's.

He had tightness in his fingers, back of his hand, distal forearm, but nowhere else. Not on his face, not on his abdomen, not on his chest, not on his legs or his feet. ANA was done and was positive one to twenty five sixty in a nuclear pattern. Other auto antibodies were done and were negative for centromere, centromere pattern or SCL70, RNP, SM or double stranded DNA. Because of the edema and the tightness in his fingers, I gave him a taper of prednisone from thirty down to five milligrams over three weeks.

He noted less swelling and puffiness. He noted improvement in the joint pain he was having in his hands and his elbows. When he returned in three weeks, I put him on methotrexate, folate, aspirin, amlodipine and lovastatin. Why the aspirin, amlodipine and lovastatin? Does not have hypertension, does not have hyperlipidemia.

I view systemic sclerosis in a limited or diffuse form to be a microvascular disease. This is my regimen of microvascular prophylaxis with aspirin, low dose amlodipine, or vasodilator and lovastatin. I've been following this man for over six months. He's done fair. His skin tightness has not progressed.

In fact, when you look at his modified Rodnan Skitt score, it was initially 14. And then in the subsequent visits, was 14, 16, 12. Last visit, a month ago, it was 14. He still has sclerodactyly. He has it tight skin up to the distal forearm.

He did have a digital pit scar, but that resolved and no, and it's been pretty minor. Raynaud's has become less of a problem with his vasodilator therapy. He does not have telangiectasis, he does not have calcinosis, he does not have esophageal dysmotility, and he does not have any further shortness of breath or organ involvement. He denies dysphasia. So Raynaud's is a minor problem.

His pain last visit was mainly in his elbow and a few fingers, morning stiffness of thirty minutes. He does not smoke tobacco, occasionally drinks coffee, sometimes six coffees a day. He's unable to work because of this condition he has. And what did I call it? Initially, called it Crest syndrome.

But then the more I see him, the more I wonder. You know, he's got a digital pitting scar. He's got above the hand, but you know, Crest, you can go all the way up to the elbow and still qualify as limited systemic sclerosis. He does not have a centromeric antibody, but he has a nuclear antibody. But then again, doesn't have an SCL70 either.

So, I'm concerned about risk, but what would you call him? Again, his skin did progress above the wrist. He did start out with shortness of breath and he has a nuclear pattern ANA, but he has no evidence of GI, renal, or lung disease. He does not have calcinosis, esophageal dysmotility, or telangiectasias. What do you call it?

I'm calling it Cress syndrome, limited systemic sclerosis, and I'm treating that as I would, as I do with methotrexate, and my regimen that goes for microvascular therapy. But what would it take for you to be more aggressive if you were doing CAR T cell therapy in your clinic? Would you give this to this man? I don't know, I might want to, but really, I have to say he has limited disease at this point. I'm calling this CREST.

What would you call it? Come to RheumNow Live and let me know what you would do. This is QD Clinic. I'm Jack Cush with RheumNow. QD Clinic is brought to you by RheumNow Live.

This is where great rheumatologists go to great meetings. February eighth and ninth in Dallas, we look to see you there. Here's the case: neck and back pain in a 43 year old man. He presents with the acute onset of neck and low back pain over a week, and he also has a polyarthritis with swollen joints in the elbow, wrist and knee. He's got a fever of 38 and a half centigrade.

And on initial evaluation, his labs look normal, but his CRP is really, really high. It's 26.5 milligrams per deciliter, or two sixty five milligrams per liter. Because he has a swollen joint, we're to joint aspiration, we're going to get imaging of his neck and his lumbar spine. The knee aspiration shows he has 73,000 white blood cells, 80% neutrophils. So, given that acute presentation, and the polyarthritis, and the septic range on the synovial fluid count, he was thought to have a presumed infection.

So he was started on general antibiotics until we were able to make a firm diagnosis. The MRI showed that he had what looked to be an effusion and inflammation of the facets between C3 and C4. And in the L in the lumbar spine between L3 and four, he had a bursitis that was a collection of fluid. So, and a repeat CT of lumbar spine showed an erosion at L4. So the question is, what is this?

Could this be an acute onset of spondyloarthritis? Could this be an acute onset of gout in the spine? Could it be that this is a septic polyarticular presentation? The synovial fluid cultures came back positive for key in your vote now. That's right.

Neisseria gonorrhoeae. Uh-oh. It was proven by nucleic acid amplification tests on synovial fluid and also from the oropharynx. He did, the patient did admit to unprotected sex. He did not have any urogenital symptoms, rectal symptoms.

He was his antibiotics were changed to ceftriaxone, where he was gonna and then he received that for twenty seven days. And this was a case of a sexually transmitted disease presenting as arthritis. Other tests for other sexually transmitted diseases, including syphilis and HIV, were negative. There was no known reason as to why this man got this. This case reminded me of a case in my residency where we had an 80 year old woman present with septic arthritis in the shoulder, and that was due to Neisseria and Gonorrhea.

So yes, you suspect that with acute monarchitis in young people. It's almost the diagnosis that has to be excluded in such presentations. But it should never go off the table. And that's the lesson of this QD clinic. Tune in for more.

We'll see you at RheumNow Live. This is QD clinic, and I'm Jack Cush with RheumNow. QD clinic is brought to you by RheumNow Live 2025, February eighth and ninth in Dallas. Meetings like this matter. Meetings like this change your thinking and practice.

Today's case is a 40 year old woman who presents back in March. Oh, that's like ten months ago, nine months ago, with a few swollen fingers that were puffy. She had a swollen left knee. And she had rainouts. And I had no other results.

I had no other labs. I gave her prednisone, a taper, and I brought her back in two weeks after labs. Her lab showed that she had an ANA that was positive at one to three twenty. That was in a nuclear, speckled, and cytoplasmic pattern. What are you going to do with that?

She had a normal sed rate and CRP, in spite of having what looked to be inflammatory arthritis. She was seronegative for rheumatoid factor and CCP, she had a mild anemia, and her CPK sed rate and CRP were normal. So, further history was negative. She had some dry mouth, maybe some mild dry eyes. And I started her on methotrexate, assuming that this was early inflammatory arthritis with lupus, or maybe seronegative RA, not too clear, maybe an overlap.

But she, six weeks later, had sudden severe, severe shortness of breath, went to a walk in clinic, and then went to the hospital, was hospitalized for, I think, almost a month. In the hospital, she was seen by pulmonary. She had lots of imaging testing and a lung biopsy. She was found to have interstitial lung disease with organizing pneumonia. And yes, the pulmonologist stopped her methotrexate.

Further testing in the hospital again showed the ANA positive, but she was now also SSA, SSB, and JO-one positive. So, in the hospital, she complained of malar, or was found to have malar depigmentation, gastritis, continued joint problems, but compared to the lungs, the lungs were the big problem. She was, you know, like a bad asthma attack, you know, gasping for air, needing oxygen. This was the dominant issue. She was given a pulse of steroids, sent home on high dose steroids and mycophenolate one thousand milligrams a day.

So I see her four weeks later, oh my god, what happened to you? And when I see her, the lung problem is no longer a problem. The steroids and the mycophenolate made a dramatic difference, but she's got horrible polyarthritis. She's got 30 tender joints. She's got 12 swollen joints.

She's on prednisone, at that time 20 or 30, mycophenolate. And the question is, what are you going to do with this? So, I looked at this and said, Well, I got to treat the arthritis. She clearly has the antisynthetase syndrome and ILD. But I'm not so clear about whether she has myositis or not.

So I am going to order a CPK. And I get back to CPK and it's 2,000. And her AST and ALT are three times the upper limit of normal. So I put her on leflinamide, the pulmonologist stopped the methotrexate. I like using methotrexate and leflunomide in inflammatory myositis.

The leflunomide will treat the arthritis, treat the inflammatory myositis. I put her on an IL-six inhibitor, and I want to get her off the mycophenolate. And that's exactly what I do. And she does great. The swollen joints go down dramatically, she gets much, much better.

But when she finally stops the mycophenolate, the joints come back. She has a rash that comes back. It's on her face, on her chest, extensor surfaces of the arms, and she has got periungal erythema. So her dermatomyositis is back, although she's not weak, and her CPK has gone down progressively from 2,000 to 600 to 178 to 35. And the question is, what are you going to do with her now?

When I asked this question on a Twitter poll, I asked what would you use in an anti synthetase overlap patient with myositis, synovitis and rapid ILD, and sixty two percent said they would use mycophenolate. It seems like her ILD has not been the problem. Her chest X-ray on repeat looked much, much better, and barely showed signs of ILD, but that might not be the best way to follow that. But she's asymptomatic. She can climb stairs.

She's not weak. So what I did was I put her back up on prednisone. I got her prednisone down to five and off of mycophenolate. I put her back up on prednisone twenty. Instead of putting her on mycophenolate, I'm going to put her on a JAK inhibitor.

The JAK inhibitor will, I think, treat the muscle disease and the arthritis, the arthritis being a big problem. Am I worried about the ILD? If I was more worried about the ILD, I probably would put her on an ILD drug like the mycophenolate. So what do the guidelines say about what you should do, with ILD? And in that case, mycophenolate and IL-six would be okay.

The expert opinions, which I've by the way, were all conditional recommendations, not grade A evidence or even grade B evidence, say that first line treatment of ILD in this situation is mycophenolate, then rituximab, cyclophosphamide and azathioprine. If they have MCTD or scleroderma, you should use the FDA approved IL-six inhibitor, right? That makes the most degree of sense here. If they have a rheumatic disease, they say you shouldn't use a TNF, leflunomide, methotrexate, abatacept, because those don't treat ILD. But these are all conditional recommendations.

So, I'm banking on the fact that she's got an overlap syndrome, an anti synthetase syndrome with a dominance of polyarthritis, myositis, and a worry about ILD. My future therapy, I believe, is going to be a JAK inhibitor with or without leflinamide. And I'm going to get her off the prednisone, I'm going to get her off the IL-six inhibitor. Be interested in knowing what you would do. Tune in for more QD Clinics.

This is QD Clinic. I'm Jack Cush with RheumNow. QD Clinic is brought to you by RheumNow Live '20 twenty five. You know, our meeting is way different than other meetings in that 45% of the meeting is devoted to you. It's all about the audience, the learners.

45 is devoted to discussion. That means panel discussions, q and a time, polling, and cases. It's way more than you'll see at other meetings. That's why it's so interesting. We hope to see you there.

This case this is a case of natural RA. RA being an unnatural disease, but can it be treated naturally? A 47 year old female with both psoriasis and psoriatic arthritis for over eleven years presents with deformities, contractures, and five swollen joints. Her current meds include curcumin, boswellia, goldenrod, a non dairy diet, St. John's wort, and 12 other natural products and nutraceuticals.

She says in the past she took prednisone twice, it made her hyper and chatty, she couldn't tolerate it. She had been offered by her dermatologist and other rheumatologists, DMARDs, or biologics, and said she read up on it, the side effects were scary, she did not do it. You figure this is going to be a challenge. This is difficult to treat RA, even though she's really not been treated. And I think when I saw this patient, my goal was to win her trust and get her involved in shared decision making.

So I have to have an open mind as to what she wants to use for natural products and vitamins, etc. You know, this is a gigantic industry. It's 01/2023. It's a $159,000,000,000 industry. More than half of your patients are taking drugs that you may or may not know about over the counter vitamins and supplements.

And the question is, are they of any benefit? And what are you going to recommend to this patient? You need to know that the data on these products is not great. So in general, the US Preventative Task Force says that there's insufficient evidence of multivitamins and supplements to prevent either cardiovascular disease or cancer in healthy, healthy adults. They recommend that diet and exercise is your best preventative.

A 2019 NHANES survey of 30,000 patients showed that supplements had no effect on mortality. You remember, we had Karen Costenbatter to a Room Now lives ago talking about the VITAL study where vitamin D and omega-three was shown to reduce the risk of autoimmune disease. But that's risk, not control. Right? But know that the VITAL study did not show that vitamin D and omega-three had any effect on cardiovascular cancer outcomes or fracture risk reduction.

And lastly, there is some data out there about the beneficial effects of curcumin, and maybe berries like cherries and things like that, which have some COX-two effects and antioxidant effects. But the Kirkman network meta analysis of 23 studies in 2,000 patients shows it was effective at lowering pain by Womack scores, overall pain scores, and the need for rescue pain medicine. So what would you do in this patient? Would you hammer on her and say, take a biologic or hit the road lady? Would you try to gain her trust by giving her an evidence based regimen and telling her not to take medicines that are not going to help her.

My view on medicines that don't help is, I need to say that they don't help. But if they don't hurt, you can the patient can continue it, as long as it doesn't cost a lot. Cush rule number seven says something like, the more the supplement costs, the less it works. That's kind of obvious to me that patients are surprised that they think that they need to buy a better probiotic, you know, an $80 a month probiotic as opposed to a $20 a month probiotic. I like probiotics, by the way.

I recommend, what's it called, PB8. It's about $20 a bottle for two months. It works pretty good. There's some evidence out there that probiotics may help inflammatory arthritis. RA, there's some evidence that says it doesn't work.

So what I would recommend in this patient, based on my experience and my understanding of the literature, is I would recommend curcumin or turmeric. Number one, I would recommend that she wants to take cherry pills. That's great too. That would take the place of maybe Advil or Celebrex. Number three, I would probably recommend an anti inflammatory diet, meaning, a non gluten, non carbohydrate, or low very low carbohydrate diet, or a Mediterranean diet, as those work really, really well.

The things that she was taking I would not support would be the Boswellia, the goldenrod, the non dairy diet, which has not been shown to work, and many of her nutraceuticals that are out there. Again, Bromelain, green tea, arnica, MSN, collagen, SAM E, SAM E3, antioxidants, CBD, ginger root, WD-forty. I mean, it gets crazy when it comes to the concern, and glucosamine. I don't recommend any of those. And again, I do like tart cherry pills as a daily anti inflammatory.

And then instructor on how to manage pain with either acetaminophen or appropriate use of over the counter nonsteroidals, making that safe. Once you have done her some respect and some good, then maybe you can talk her into the safety, and potential benefits of therapies that she's refused to take. That would be my approach to the patient with natural RA.