Friday recall — anabolics: Teriparatide, abaloparatide (PTH), romosozumab (anti-sclerostin) Very-high-risk → anabolic FIRST, then antiresorptive; never reverse Romosozumab: CV boxed warning, avoid after recent MI/stroke GIOP: protect early at low-dose steroids

Board trap: romosozumab builds bone fast by blocking sclerostin — but it carries a cardiovascular boxed warning. Avoid it in patients with an MI or stroke in the past year. The right drug for the bones can be the wrong drug for the heart.

Case: a 68-year-old woman on alendronate fractures her hip with minimal trauma. DXA T-score −3.4. Her physician doubles down on the bisphosphonate. Best move?

Resident pearl: anabolics aren't last-resort. For very-high-risk patients — T-score ≤ −3.0, recent fracture, or fracture while on an antiresorptive — build bone FIRST with an anabolic, then lock it in.

Mnemonic Monday — anabolics build bone: the PTH twins teriParatide and abaloParatide (both have Para), plus romosozumab. The flip: each must be followed by an antiresorptive, or the new bone you built melts away.

Friday recall — antiresorptives: Bisphosphonates: bind bone, block clasts; holiday after 5y oral / 3y IV Denosumab: anti-RANKL; NO holiday — stopping = rebound fractures, always bridge Watch: atypical femur fracture, osteonecrosis of the jaw

Board trap: dull, aching thigh or groin pain in someone on long-term bisphosphonate or denosumab isn't just arthritis — think atypical femur fracture. Subtrochanteric, transverse, often bilateral, and visible before the bone fully breaks. Image both femurs.

Mnemonic Monday — bisphosphonates, the 3 B's: they Bind Bone and Block osteoclasts. The flip: take on an empty stomach with water and stay upright 30–60 minutes, or you risk pill esophagitis.

Case: a 74-year-old woman has taken denosumab for 4 years and wants to stop for cost. Her doctor agrees and simply discontinues it. Three months later — acute back pain. What happened?

Resident pearl: bisphosphonates earn a drug holiday after ~5 years oral / 3 years IV in lower-risk patients — they linger in bone and keep working. Denosumab does not. There is no denosumab holiday.

Friday recall — osteoporosis basics: Clasts consume, blasts build Dx: T ≤ −2.5, OR fragility fracture, OR high FRAX T-score = vs young adult; Z = vs same age Treat at FRAX ≥3% hip / ≥20% major

Board trap: a normal DXA T-score does NOT rule out high fracture risk. A prior fragility fracture or a high FRAX score diagnoses osteoporosis regardless of BMD. Treat the risk, not just the number.

Wednesday Q: a 45-year-old premenopausal woman gets a DXA. Do you report her bone density as a T-score or a Z-score — and who gets which?

Resident pearl — the highest-yield mechanism in bone: RANKL (the demolish order, mostly from osteocytes) binds RANK to make osteoclasts; OPG is the decoy that mops up RANKL. Mnemonic: RANK says WRECK; OPG says protect.

Mnemonic Monday — how do you build bone? "Wnt? Why not build!" The Wnt signaling pathway tells a mesenchymal stem cell to become a bone-building osteoBlast. Block Wnt — which is exactly what sclerostin does — and the pour crew slows; lift that brake with romosozumab and building resumes.

New on the Rheumify Substack — Osteoporosis Module 1: bone remodeling and why the osteoclast/osteoblast tug-of-war decides who fractures. https://open.substack.com/pub/rheumify/p/osteoporosis-module-1

ScriptCycle for Rheumatology just got AI agents — they draft cover letters, suggest target journals, and triage your paper ideas. It runs your whole publishing cycle (manuscripts, submissions, abstracts) in Notion. Still free: notion.com/templates/scriptcycle

Friday recall — GCA in one screen: Who: >50, new headache, jaw claudication, vision loss, scalp tenderness, PMR overlap Labs: high ESR/CRP (can be normal) Dx: temporal artery biopsy or ultrasound halo Tx: steroids NOW; tocilizumab to spare steroids pubmed.ncbi.nlm.nih.gov/34235884

Board trap: a negative temporal artery biopsy does NOT rule out GCA — pooled sensitivity is only ~61%. Skip lesions and large-vessel-predominant disease mean biopsy can miss it. If suspicion is high, treat and image. pubmed.ncbi.nlm.nih.gov/33811481

Vision loss in GCA is usually arteritic anterior ischemic optic neuropathy — from occlusion of the posterior ciliary arteries that supply the optic nerve head, not the central retinal artery. Once it's lost, it rarely comes back. pubmed.ncbi.nlm.nih.gov/9559737

Resident pearl: suspect GCA? Start high-dose steroids now — don't wait for biopsy. In a VA cohort, delaying prednisone 14–28 days after diagnosis tripled 1-year ophthalmic complications in biopsy-negative patients. pubmed.ncbi.nlm.nih.gov/33417014

GCA week. Of all GCA symptoms, jaw claudication carries the highest likelihood ratio for a positive temporal artery biopsy. Masseter pain that builds while chewing and eases with rest is ischemia, not TMJ. pubmed.ncbi.nlm.nih.gov/11754714

ANCA vasculitis pearl: PR3/c-ANCA skews toward GPA, MPO/p-ANCA toward MPA — and PR3 positivity predicts higher relapse risk, which shapes how long you maintain therapy.

ANCA vasculitis pearl: for remission maintenance, scheduled rituximab outperformed azathioprine at preventing major relapse (MAINRITSAN). pubmed.ncbi.nlm.nih.gov/25372085

ANCA vasculitis pearl: PEXIVAS reset two habits — plasma exchange did NOT reduce death or end-stage kidney disease in severe AAV, and a reduced-dose glucocorticoid regimen was noninferior with fewer serious infections. pubmed.ncbi.nlm.nih.gov/32053298

ANCA vasculitis: the FDA is moving to withdraw avacopan (Tavneos), alleging ADVOCATE remission endpoints were re-adjudicated after database lock — flipping a nonsignificant result to significant — and citing 76 serious liver-injury cases. Comment by June 29. fda.gov/media/192160/download

Friday recall — ANCA in one screen: c-ANCA / PR3 → GPA (airway + kidney) p-ANCA / MPO → MPA (kidney + lung) & EGPA (asthma + eosinophilia) Induction: rituximab or cyclophosphamide + steroids.

Board trap: a negative ANCA does NOT rule out vasculitis. ~50% of EGPA is ANCA-negative, and limited GPA can be too. ANCA supports the diagnosis; tissue + clinical picture make it. Treat the patient, not the titer.

Resident case: 58M, months of bloody nasal crusting + a new saddle-nose deformity, now hemoptysis and Cr 2.4 with RBC casts. What test do you order while awaiting the results of the renal biopsy?

Resident pearl: think GPA when you see the triad — destructive upper airway (saddle nose, chronic sinusitis), pulmonary nodules/hemoptysis, and pauci-immune glomerulonephritis. Upper + lower airway + kidney.