Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to treatment of lupus peritonitis?
Lupus peritonitis is difficult to treat and there are no evidence-based approaches, to my knowledge. I think ruling out other causes like malignancy, infection, perforation, thrombosis, liver disease, and renal/cardiac causes, as well as malabsorption and malnutrition, is the first step. Then I ...
How do you monitor response to treatment in patients with mononeuritis multiplex secondary to vasculitis?
As the reinnervation process is slow (nerve regrowth speed estimated at 1mm/day), clinically discernible neurological improvement in vasculitic neuropathy may not be observed until weeks to months later. In addition, the full spectrum of electrophysiological abnormalities may not be seen until a few...
What treatment options are available for patients with spondyloarthritis who develop biologic-induced psoriasis?
Management of patients in these situations is quite challenging and the approach should be individualized. Biologic induced psoriasis is most commonly seen with TNF-α inhibitors as a paradoxical response. However, this has also been rarely described with other biologic agents: Interleukin-6 blockers...
How do you manage arthralgias with subclinical synovitis seen on US or MRI?
The holy grail of rheumatology is to prevent the onset of clinically apparent arthritis as most leaders in the field believe that early treatment may prevent onset of overt arthritis and lead to drug-free remission. Unfortunately, the issue is much more complex than imaging alone to define early dis...
Is there a role for G-CSF treatment for SLE patients with persistent neutropenia?
There may be a role for G-CSF for treatment of SLE-related neutropenia, though would recommend using with caution only for severe neutropenia (ANC less than 500) and at lowest dose. The use of G-CSF has been looked at in small case series over the years for both SLE patients with neutropenia and Fel...
Do you consider low-dose aspirin for primary thromboprophylaxis in patients with high-risk antiphospholipid antibody profiles?
Yes, I offer low dose aspirin for patients with high titer anti phospholipid antibodies. The patients often agree unless they are concerned of increased risk of bleeding due to their profession or hobbies, such as horseback riding. I do not recall such adverse events. Nevertheless, controlled trials...
Is there a role for anti-IL6 therapy in SSc-associated ILD?
There may be a role for IL-6 inhibition for the treatment of ILD in scleroderma, but this has not been fully explored yet in clinical trials. However, the Phase II and Phase III studies of tocilizumab both suggested stabilization of FVC compared to the placebo arm. The Phase III faSScinate study inc...
Do you recommend the use of contrast to identify sacroiliitis on MRI?
If axial spondyloarthritis is suspected, and Xray of pelvis is either normal or equivocal then an MRI of SI joints is ordered to support the diagnosis of axial spondyloarthritis. The recommendation by ASAS is to order 2 sequences, T1-fat enhancing sequence, and a STIR- fat suppression sequence witho...
Do you image the spine in addition to the sacroiliac joints when you suspect axial spondyloarthritis?
This is a great question and a single correct answer does not exist. Axial SpA affecting the spine without SI joint involvement does occur but is seen in a minority of the patients. The exact prevalence is hard to determine due to lack of longitudinal data as well as significant variability in prese...
How do you approach immunosuppressive therapy in lupus-associated pulmonary arterial hypertension?
I agree with Dr. @Dr. First Last that pulmonary arterial hypertension in SLE is infrequent. In the October issue of arthritis and rheumatology, the prevalence was 2.54% in a cohort of Chinese patients. Management requires distinguishing amongst the 5 WHO groups of PAH, which in lupus includes the fo...