Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is it safe to use statins in IIM patients if HMGCR antibodies are negative?
Absolutely, yes. Statins are a very important drug for patients with cardiovascular disease and should be given to most patients with myositis except patients with known immune-mediated statin myopathy or HMGCR Positive antibody. I would monitor CK levels before and 3 and 6 months post statin, as we...
Is there a role for PCSK9 inhibitors in patients with statin-associated immune mediated necrotizing myopathy?
The majority of patients with statin-associated immune mediated necrotizing myopathy are in need of cholesterol-lowering medications. While one can try other strategies (like diet or ezetimibe), these are usually inadequate. Therefore, I would advocate for PCSK9 inhibitors as first-line treatment, w...
What is your approach to treating refractory thrombocytopenia in lupus?
Refractory thrombocytopenia is challenging to treat. It is important to evaluate for non-SLE causes including infection, medications, and malignancy. It is also important to differentiate ITP from TTP/atypical HUS. Once the ITP diagnosis is confirmed, I usually don't treat asymptomatic thrombocytop...
What do you use for treatment induction in pure class V lupus nephritis with nephrotic-range proteinuria when MMF is contraindicated?
I'll begin my response by commenting that other than an allergic reaction, which is very rare or pregnancy, there is really no absolute contraindication to MMF. On the other hand, there are patients who cannot tolerate MMF most often due to G.I. side effects in which case mycophenolic acid is an opt...
Are there particular concerns related to the use of B-cell depletion therapies such as rituximab for rheumatic disease during the COVID-19 pandemic?
The attendant depletion of CD20+ B cells associated with treatment with rituximab likely results in impaired development of host immunity to previously unrecognized microbial pathogens. This has, therefore, been of concern in the context of the Covid-19 pandemic due to potential greater adverse outc...
How does the presence of myositis alter your interpretation of cardiac enzymes when evaluating acute chest pain?
Troponin T and CK-MB are not reliable for cardiac issues in myositis as regenerating muscles produce these enzymes. This is especially true if the patient has an active disease with weakness and CK elevation. Troponin I is not much affected by muscle enzymes and should be used as a parameter to eval...
What is the biologic of choice in a patient with RA and history of non-melanoma skin cancer?
We have long known that patients treated with TNF inhibitors (TNFi) have a higher risk of developing non-melanoma skin cancers. For this reason, all patients prescribed these drugs should undergo annual full-body dermatology skin exams. If this recommendation is followed, there should be no contrain...
What are the benefits of sending HLA B27 genotype over HLA B27 antigen when evaluating for spondyloarthritis?
HLA-B27 is strongly associated with ankylosing spondylitis (AS) which is an inflammatory rheumatic disease that affects the spine, the sacroilliac joints, and peripheral joints. It is also associated with other diseases like acute anterior uveitis, inflammatory bowel disease, or psoriasis. HLA-B27 t...
How do you approach patients with overlapping features of PMR and seronegative RA?
To me, this is the same as saying how to treat large and small joint rheumatoid arthritis in the same patient. For me, the difference is largely in the use of steroids. I have used much less steroids in my patients who I believe to have small joint seronegative rheumatoid arthritis, initiating a DMA...
Are you recommending the mRNA COVID-19 vaccines to your patients with immune mediated inflammatory diseases?
This is THE question at the moment for providers of patients with immune mediated inflammatory diseases. For now, we are merely extrapolating as patients with active IMIDS were censored from trials (Pfizer & Moderna). Organizations like the American College of Rheumatology are moving quickly to clos...