Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there any situations in which you would consider starting steroid-sparing agents at the outset for patients with scleritis without any evidence of systemic rheumatic disease?
The average duration of scleritis is 7 years. The duration distribution is a bell-shaped curve, meaning that some patients have shorter disease duration but others have longer disease duration. Unless the ANCA is positive or an obvious systemic disease is present, it is very hard to know who will ha...
How long do you wait for response to corticosteroids and conventional synthetic DMARDs before considering IVIG in patients with HMGCR antibody positive IMNM?
Although it is possible to use IVIG monotherapy as initial treatment of anti-HMGCR myositis (without the use of steroids), it is not always possible depending on the medical insurance or patient preference. So, in case of steroids/steroid-sparing agents, I would monitor for improvement of symptoms 2...
In gout, do MSU crystals form only in tissue, or are there circulating microcrystals of MSU within blood vessels?
The solubility of MSU is dependent upon solute, temperature, and pH. Even with a rapid rise in total body uric acid as seen with tumor lysis syndrome, where uric acid levels can exceed 15 mg/dL, I have never heard of an MSU crystal identified in a serum sample. As I explain to students and patients,...
Is it ever appropriate to use hydroxychloroquine temporarily in higher doses (more than 5mg/kg) to control lupus activity such as skin manifestations?
The risk of retinal toxicity with long-term use of doses higher than 5mg/kg was shown by Melles and Marmor; PMID 25275721. There are reports of developing retinal toxicity even with short-term use of HCQ mostly coming from oncology literature (e.g. Navajas et al., PMID 26651304).There is some publis...
Is there an increased risk of COVID-19 in patients on immunosuppressants?
This is an important question to which there is no clear answer. Intuitively, it would be expected that patients who are immunosuppressed would be at greater risk of Covid infection. However, observational studies suggest that this may not be the case. Haberman et. al., have reported the results of ...
Would you hold all immunosuppressive medications for the first month of LTBI treatment, or just biologics?
This video might answer your question: QD Clinic - Lessons from the clinic - Dx and Treating LTBI with a TNFI inhibitor features Dr. Jack Cush
Which immunosuppressed patients with SLE would benefit from antibiotic prophylaxis to prevent pneumocystis pneumonia?
Starting PCP prophylaxis in patients with lupus is controversial. We typically start lupus patients on PCP prophylaxis if they have underlying ILD and are on doses of steroids of 20 mg or higher. I also consider starting PCP prophylaxis in lupus patients while they are receiving cyclophosphamide and...
In what situations do you consider platelet-rich plasma injections in patients with osteoarthritis?
The literature on this topic is sparse, largely confined to discussions of knee OA, and unconvincing of real benefit. I would like to see well-designed clinical trials dedicated to the benefit of PRP in OA. I honestly cannot think of a situation when I would consider PRP injections for osteoarthriti...
Do you recommend using IL-1/IL-6 inhibitors in COVID-19 multisystem inflammatory syndrome in adults (MIS-A)?
There are very few published reports on the COVID-19 multi-inflammatory syndrome in adults (MIS-A), so most of the evidence is extrapolated from the experience of multi-inflammatory syndrome in children (MIS-C). MIS-A seems to occur very infrequently, typically in young adults, despite COVID-19 seve...
Should venous thrombosis in a patient with Behcet syndrome be treated with both immunosuppression and anticoagulation?
They should be treated with immunosuppressive medications, however, the additional benefit of anticoagulation is much debated. Various studies and metaanalysis have shown that anticoagulation, on average, does not add any benefit. There may be exceptions to this in the early part of treatment for so...