Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
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...