Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is the biologic of choice in a patient with RA and myasthenia gravis?
There is no biologic of choice for patients with Myasthenia Gravis (MG). Given the disease's rarity, the data is scant. A prospective pilot trial of etanercept in 11 patients with corticosteroid-dependent observed that 6 of the 8 patients who completed the trial improved, based on quantitative measu...
How do you approach anticoagulation in patients with catastrophic antiphospholipid syndrome and thrombocytopenia?
Due to the rarity of CAPS, there are no evidence-based guidelines available and most treatment is empiric or based on expert guidance. Most would agree that the mainstay of treatment is anticoagulation, and the preferred anticoagulant is unfractionated heparin. In a recent guideline paper, therapeut...
Which EGPA patients are most likely to benefit from treatment with anti-IL-5 agents such as mepolizumab?
This is a question that is an important area of current investigation in vasculitis. In my view, patients who have primarily pulmonary and sinonasal symptoms (e.g., asthma, rhinosinusitis) are most likely to benefit from mepolizumab, given current knowledge.It is unknown to what degree mepolizumab a...
What is considered an adequate treatment period to assess response of AAV induction therapy with rituximab or cyclophosphamide?
This is an issue of considerable interest both clinically and for research studies, and the approach to both settings is currently similar: are there any signs or symptoms of ongoing active disease? The key words being “ongoing” and “active”. The expectation once glucocorticoids are started and then...
Are there AAV patients for whom you would consider combination therapy with cyclophosphamide and rituximab?
The combination of RTX and CYC does not have a significant evidence base. The rationale for this regimen comes from the hypothesis that CYC acts quicker than RTX and can serve to quiet down the disease early and potentially spare steroids. However, there is no empirical support for this concept so f...
How would you treat uveitis in a patient with a history of cutaneous T cell lymphoma?
In chronic uveitis patients where systemic therapy cannot be used, local steroid injections/implants can be useful. This question does not specify the type of uveitis, so it is difficult to answer. But in general, for anterior uveitis, sub tenon triamcinolone can be used which lasts 6 months. In oth...
Do you switch to certolizumab in RA patients who are doing well on other TNFis and planning to become pregnant?
I have not “switched” any patients who are stable and doing well on an anti-TNF agent when the issue of pregnancy arises. The risk of flare remains a concern in this situation. There is enough data-base derived information (such as the OTIS registry) to suggest safety to continue an established anti...
How would you approach localized lymphadenopathy in a patient with lupus whose symptoms are otherwise well-controlled?
Localized adenopathy in lupus is infrequent and the differential is broad including nonspecific reactive hyperplasia as part of underlying illness or local trigger, infectious (e.g., suppurative in association with staph or strep, MTB, atypical mycobacterium, fungal, etc), lymphoma (e.g., Hodgkin's ...
Are you recommending tocilizumab for any COVID-19 patients?
The utility of IL-6 receptor inhibitors in COVID-19 is controversial, and I do not recommend its routine use in COVID-19 patients at this time. Although early observational studies of IL-6 receptor inhibitors in severe COVID-19 suggested potential benefits, an early RCT of tocilizumab vs. placebo (B...
Do you find addition of quinacrine to methotrexate or mycophenolate helpful in treatment of refractory CADM?
Anti-malarials are definitely one of the options for treating the skin manifestations in CADM, but the first line drug of choice would be hydroxychloroquine either alone or in combination with other DMARDs like methotrexate. In cases of either hydroxychloroquine failure or toxicity [retinal pigmenta...