Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there a role for the VECTRA or other multi-biomarker tests in evaluating rheumatoid arthritis disease activity?
Yes. I find VECTRA very reliable and helpful in my community rheumatology practice. The reliability of the test has increased since its modified version came into the market a few years ago. VECTRA is an objective measure of disease activity in patients who already carry a diagnosis of RA. It should...
For which subset(s) of APS patients do you recommend an INR of 3 or higher?
According to the EULAR 2019 recommendations for managing APL (Tektonidou et al., PMID 31092409) and according to the 2011 APL Task Force recommendations: For secondary venous thrombosis prophylaxis, it is recommended to keep INR between 2-3. Patients who fail warfarin therapy at INR 2-3 may benefit ...
What is your approach to a patient with positive antiphospholipid antibodies who otherwise do not meet clinical criteria for APS?
As antiphospholipid antibodies constitute a diagnostic criterion of SLE, such patients may need to be evaluated and monitored long term for both SLE and APS.
Do you avoid any specific biologic therapies in HIV positive patients?
At present, the most safety data on the use of biologics in HIV is TNF inhibitors. CD4 count should be > 200 and VL undetectable. Etanercept is most preferable, give lower incidence of serious infections as well as its efficacy as monotherapy (without methotrexate). Wangsiricharoen et al., PMID 2733...
Are there any therapeutic options for cauda equina syndrome secondary to dural ectasia in end-stage ankylosing spondylitis?
The cauda equina syndrome is a rare complication in patients with ankylosing spondylitis (AS). Patients with longstanding disease leading to significant ankylosis of the spine have the highest risk of developing it. The likely underlying mechanism is arachnoiditis leading to damage of the lumbosacra...
How do you treat RA in patients with pulmonary mycobacterium avium complex (MAC) infections?
This is a very complex situation and requires teamwork between rheumatology and infectious disease with close patient follow-up and treatment. In general, avoiding TNF inhibitors in these patients is preferred, in particular the monoclonals, with close monitoring. Methotrexate is an option, and in t...
Do you think there is a role for belimumab in treating lupus nephritis and if so, in which patients would you considering adding it on?
The results from BLISS-LN showed modest efficacy as an add-on therapy to standard of care. The improvement was significant only in the non-black patients receiving mycophenolate mofetil (MMF) as standard of care. The primary endpoint was changed in the midst of the trial but still, the complete rena...
What agents can you use for treatment induction besides rituximab in cryoglobulinemic vasculitis (without hepatitis)?
The choice of induction/immunosuppression depends on the severity and is very similar to small vessel vasculitis like ANCA-associated vasculitis. So in addition to rituximab, cyclophosphamide is a very good induction agent for severe forms. This is one condition where plasma exchange is highly recom...
What is your inflammatory arthritis differential when a patient presents with unilateral TMJ synovitis?
The differential of TMJ disease depends on the age group. In the younger population, JIA must be very high on the differential. In adults, the differential includes RA, dermatomyositis, systemic sclerosis, systemic lupus erythematosis, and spondyloarthropathies (Ankylosing spondylitis and psoriatic ...
What is your approach to screening for cardiac involvement in patients with myositis and how does the finding of cardiac involvement change your management?
Cardiac involvement in IIM can often be overlooked but reportedly occurs at a high rate (~up to 75%) in a subclinical fashion. This can run the gamut of myocarditis, arrhythmias, conduction defects, cardiomyopathy, heart failure, and atherosclerotic disease. Screening for this often starts with an E...