Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How does your treatment algorithm differ for drug-induced ANCA vasculitis compared to non drug-induced ANCA vasculitis in cases with severe/organ-threatening manifestations?
When end-organ manifestations are present, my initial treatment approach is similar for drug-induced and non-drug induced AAV and typically consists of glucocorticoids and rituximab, including pulse glucocorticoids with severe end-organ involvement. Common drug culprits such as PTU, hydralazine, min...
What is your approach to monitoring lipids in patients with rheumatic diseases such as RA and SLE and do you have a lower threshold to start lipid lowering agents compared to the general population?
In patients with SLE/RA, there is a higher risk of cardiovascular disease compared to age-matched controls. This is multifactorial from underlying traditional risk factors such as obesity, HTN, DM, HLD, but may also be increased due to side effects of steroids, biologics, and other medications, and ...
How long do you continue steroid-sparing agents such as tocilizumab for GCA once the disease is in remission off steroids?
This is an excellent question and one we confront regularly. This is another of what I call “happy problems” because it is a consequence of increasing options for effective therapy for our patients.Tocilizumab is clearly an effective agent for some patients with giant cell arteritis (GCA), and patie...
How would you attempt to determine the etiology of intracranial hemorrhage in a patient with newly diagnosed lupus and an active viral infection?
My typical evaluation of a case like this is as follows: 1. Evaluate their lupus disease activity: CBC, CMP, ESR, CRP, C3, C4, dsDNA, urinalysis, urine protein/creatinine ratio (latter two are more for eval of renal disease) 2. Evaluate the cause of ICH: a. MR to further evaluate for other non-ICH r...
Do you monitor RS3PE patients for GCA with the same vigilance that you do in PMR patients?
I don't think there has ever been a confirmed case of GCA in someone with RS3PE. In this way, RS3PE is more similar to seronegative RA than PMR. However, it is possible that some patients with RS3PE may have overlapping features with cases of PMR, such as describing shoulder and hip girdle stiffness...
Which patients may benefit from eculizumab in refractory APS?
I do not know of any scheme/plan/approach that ahead of time would determine accurately and unequivocally if eculizumab would work. Having a low C4 and/or C3 serum level would suggest that the APLS antibodies are fixing complement. In other words, complement activation may be contributing to the pat...
Do you use leflunomide in rheumatoid arthritis patients on hemodialysis?
Leflunomide has been used in patients with RA on hemodialysis. Several small pharmacokinetic studies suggest that dose adjustment is not needed (Bergner et al., PMID 23179005, Beaman et al., PMID 11816264).
What is your first choice contraceptive agent for women with SLE?
In general, I recommend either IUD (progesterone or copper) or nexplanon due to the safety profile as well as efficacy. Progesterone IUDs can be safely used for all lupus patients as well as those with APS. Copper can as well but would use caution in patients with APS on therapeutic anticoagulation ...
How do you counsel Takayasu patients on their prognosis?
Unfortunately, patients with Takayasu arteritis have a higher mortality rate compared to the general population. Most studies suggest a 3-fold higher standardized mortality rate in patients with TAK compared to age-matched healthy controls. Survival rates following TAK diagnosis vary notably between...
Is it appropriate to consider biologic therapy for treatment of RA in a patient with non-small cell lung carcinoma treated with radiation therapy, who has ongoing active synovitis uncontrolled by conventional DMARDs?
Yes, active RA needs to be treated, and starting biologics should be considered after failing conventional DMARDs; there is no contraindication to the use of biologic in patients with previously treated solid malignancies like lung cancer as per 2015 ACR guidelines. The new 2020 guidelines are to be...