Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Does the presence of facet joint effusions on lumbar spine MRI increase your suspicion for axial spondyloarthritis?
Isolated joint effusions in the lumbar spine are not indicators of AxSpA. Involvement in the spine in AxSpA involves more than the facet joint including adjacent entheses linking one vertebra to another and the costochondral joints. To arrive at this answer, I spoke to rheumatologists with expertise...
Are there concerns with using sulfasalazine in SLE?
A very practical question:1. Yes, there is a concern theoretically; but you can use SSZ in lupus patients in certain circumstances.Sulfonamides are divided up into antibiotic (abx) sulfonamides (like trimethoprim-sulfamethoxazole, TMP-SMX) and non-abx sulfonamides (e.g. furosemide, hydrochlorothiazi...
How often do you monitor labs in patients taking methotrexate?
Lab monitoring for patients taking MTX should be based on a few key principles. It should be done at least on a quarterly basis, ie every 3 months, if the patient is prescribed a stable dose and does not belong to one of the higher risk categories for the development of toxicities. These risk factor...
How would you treat inflammatory arthritis in a patient with Sjogren's syndrome and ILD (on mycophenolate) that is not responsive to hydroxychloroquine?
Fortunately, the Sjögren's Foundation has worked hard in providing us with evidence-based guidelines to answer these sorts of questions. I would go by the "Treatment Guidelines for Rheumatologic Manifestations of Sjögren's." The working group using the Delphi consensus process did all the hard work ...
How would you approach the work up of SLE in a patient over 80 years old?
Elderly onset lupus is uncommon and in the past twenty-five years has been reported to occur in as few as 6% of patients to as many as 19% of patients with the diagnosis of lupus. Typical clinical presentations tend to include arthritis/arthralgias, fever, weight loss, lymphadenopathy, serositis, si...
What is your treatment approach to persistent chillblains lesions in the absence of systemic lupus?
In idiopathic chillblains/perniosis, I think treatment centered on lifestyle modifications is key. As this is a cold-associated dermatosis, counseling patients to wear warm gloves or socks and avoiding cold exposure is important. Beyond lifestyle modifications, I typically start with a high-potency ...
Is there a role for voclosporin in non-renal lupus?
I would say "no." Plus, I'd be amazed if anyone could get insurance to cover it for any lupus patient who does not have lupus nephritis. The voclosporin (VOC) phase 2 clinical trial (AURA-LV by Rovin et al., PMID 30420324.) showed improvements in the SELENA-SLEDAI score (lupus disease activity measu...
What characteristics make a PMR patient a good candidate for sarilumab?
As rheumatologists, we are familiar with sarilumab, so we may already be comfortable using this medication. It has a role to play in managing patients with some of the following issues: Those who are struggling with early steroid tapers, i.e., not successfully tapering from 10 down to 5 mg/qd. Pati...
Do you pursue a malignancy workup beyond age-appropriate malignancy screening in patients with antibody negative necrotizing myopathy?
This is a great question that speaks to the nuanced (and still-being-elucidated) association between malignancy and the increasingly better sub-divided different autoimmune myositis subtypes:While anti-SRP and anti-HMGCR are the two myositis-specific antibodies (MSA) most closely associated with imm...
In a patient with neurosarcoidosis who required infliximab for initially refractory symptoms but is now stable, how do you decide on the optimal time to de-escalate therapy?
I typically base this decision on several factors: Severity of initial symptoms, tolerability or side effects of treatment, degree/timeline of radiographic improvement, and patient preferences. I begin to consider tapering off or de-escalating infliximab after around 12-24 months of clinical and rad...