Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
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...
What isolation policies are Rheumatology offices employing for both staff and patients diagnosed with COVID-19 given the new CDC guidelines?
Still the same: masking in all settings.
Would you start anticoagulation in a patient with a history of CVA 1 year ago and high risk APL profile who was never started on anticoagulation, but is now presenting for follow up and without recurrent thrombotic events?
This is a difficult question. The details here are important. Therapeutically, you can go either way in my opinion. Were the positive antiphospholipid antibodies checked again later? Did the patient have an infection when the APS labs were first done? Does the patient have diabetes or other CV risk ...
What is your approach to a patient with IgG4RD with past pulmonary involvement (biopsy proven) managed with steroids alone, now with new hematuria/proteinuria, but stable renal function?
Significant hematuria is not a typical feature of IgG4-related kidney disease. IgG4-RKD most commonly presents as tubulointerstitial nephritis (TIN), which presents as mild, non-nephrotic range proteinuria. In fact, urinalysis in the context of TIN is often normal, as the proteinuria is largely non-...
How do you manage nausea in the setting of hydroxychloroquine use?
My method for approaching hydroxychloroquine (HCQ)-induced nausea: Stop HCQ When nausea is gone, restart with just 1/2 tablet every night after food or milk(I recall a study suggesting that nocturnal use caused less side effects, but I cannot find it. If anyone has the source, please chime in). A we...