Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there certain patients in whom you would avoid initiation of ULT during an acute gout flare?
Yes, I usually avoid it during first-time visits for gout flares. This is because the amount of information required during that visit would include: The acute gout flare management, and Information about gout in general. Commonly, this is in addition to other intercurrent medical problems. Addin...
How will you sequence therapies in dermatomyositis given the results of the ProDERM trial?
I will try oral immunosuppressants first, either methotrexate, azathioprine, or mycophenolate first; and then add IVIG if there is no response or even minimal response.
What is the approach to use of ACE inhibitors for suspected scleroderma renal crisis in patients with only mildly elevated BP and renal artery stenosis?
I recommend using a short-acting ACEi, like captopril, to treat scleroderma renal crisis. You can start at 6.25mg TID and rapidly titrate up the dose to achieve blood pressure goals. The presence of renal artery stenosis (RAS) would not dissuade me from using an ACEi, if there is evidence of thrombo...
How do you approach transaminase elevations with use of allopurinol in gout?
This is quite rare in my practice of the use of allopurinol. That may be because I discourage NSAID concomitant use in people with gout, given their concomitant hypertension, and NSAID-associated GI, renal, and liver toxicity. 1. If mild transaminitis happens, I would approach it as I do for any pat...
What is your approach to management of persistent painless salivary gland swelling/sialadenitis in patients with Sjogren's?
This is a common problem in this patient population, and we had Rheumatologist send to worry about physical findings that we are having trouble explaining. In this particular situation, the printable concern would be for sites of damage. Unfortunately, there are no known immunologic interventions th...
How do you manage patients with systemic sclerosis and chronic thrombotic microangiopathy on renal biopsy, but no other evidence of scleroderma renal crisis?
Very good question. Disclaimer 1st - I am not a nephrologist or nephropathologist so this really requires putting many heads together! Thrombotic microangiopathies (TMA) are clinical syndromes defined by the presence of hemolytic anemia, thrombocytopenia, and organ damage from micro thrombosis in ca...
What are the reasons for SLE specific labs to turn negative?
I agree and appreciate the answers by Dr @Dr. First Last and Dr @Dr. First Last. My answer may be stating the obvious, but I think it is important to mention that lupus is not infrequently over-diagnosed and overtreated. Serologies are sometimes over-interpreted with low-titer antibodies labeled as ...
What is your approach to monitoring a patient with SLE who has persistent hypocomplementemia on hydroxychloroquine, but clinically has resolution of cutaneous symptoms and no other internal organ manifestations of disease?
Per the subtitle under your question, an undetectable C4 with low C3 makes me wonder about the possibility of a homozygous C4 deficiency, of whom 75-80% of patients have SLE with a high occurrence of lupus nephritis (Yang et al., PMID 15294999). You can consider genetic testing (primarily for geneti...
How do you approach management of patients with inflammatory arthritis who are asymptomatic but develop radiographic progression?
Radiographic disease progression remains the gold standard test for assessing disease activity in patients with RA. Therefore, any time one notes progression of radiographic change, this finding needs to be taken seriously. Since plain radiographs may take many months or years to demonstrate such ch...
Do you use immune checkpoint inhibitors in NSCLC patients with pre-existing, well-controlled autoimmune disease?
While there is limited data on the use of PD1 inhibitors in patients with pre-existing autoimmune conditions; in patients with metastatic NSCLC with limited options, it warrants consideration. This is obviously a high risk population to treat and close monitoring and co-ordinated care with specialis...