Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach treatment of rheumatoid arthritis in a patient with an active hematologic malignancy (such as leukemia or lymphoma) after methotrexate failure?
Clearly, a multidisciplinary approach is important. The first consideration is of the hematologic malignancy and preferred treatments for it; as B cell depleting agents may also help control the RA. As experience with combination biologics has only shown increased adverse events and lesser efficacy,...
Is it okay to use medications associated with drug-induced lupus in patients with SLE?
In the current era, I find it useful to divide drug-induced lupus into two classes. First, the traditional medications such as procainamide and hydralazine that are associated with ANA by IFA, anti-histone antibodies, and a type of drug induced lupus not characterized by certain clinical features su...
How would you manage an active rheumatoid arthritis patient on suppressive antibiotic therapy for ocular HSV who has abnormal liver function tests?
As an ophthalmologist, I will answer this selectively. The choice of immunomodulation for RA in the setting of liver dysfunction, I would defer to rheumatology (I do know that there are plenty of appropriate options that minimize risk to the liver). As far as the ocular HSV, I have many patients wit...
How would you manage methotrexate therapy in an active rheumatoid arthritis patient undergoing treatment for latent TB with rifampin?
There are no easy answers as both rifampin and INH combined with methotrexate are associated with enhanced hepatotoxicity. Monotherapy regimens, while generally well tolerated can cause hepatotoxicity leading to dose modification/interruption in about 5-10%. All approved regimens can be tried depen...
When would you recommended restarting biologic medications in an active RA patient after treatment with monoclonal antibodies, convalescent plasma or antiviral medications for a COVID-19 infection?
As rheumatologists, we are accustomed to medical decision making in data free zones. This is what we face here too. There are no studies that have directly addressed these issues- nonetheless, the likelihood of meaningful drug interactions between a biological drug for RA and these various anti-vira...
How do you clinically distinguish between cutaneous lupus with photosensitivity and polymorphic light eruption-like reactions?
Polymorphous light eruption (PMLE) typically occurs at the onset of Spring or Summer when patients have been exposed to light for the first time that season. Because patients' faces are usually not covered up, even in the winter (in non-COVID times), they usually continue to get sun on their faces. ...
What are your thoughts on use of 14-3-3 serum levels in rheumatoid arthritis in conjunction with RF and ACPA?
Until we have a perfect test, it's always worth considering new tests for rheumatoid arthritis (RA). And there are hints that this test may be useful.14-3-3eta is a member of a family of chaperone proteins found in the serum of some patients with RA and other rheumatic diseases.Studies suggest this ...
How do you approach dosage changes of allopurinol as a patient's GFR decreases over time?
Usually, there is no need to adjust the allopurinol dose for a gradual decline in GFR with aging. The renal dose adjustment for allopurinol is for the initial dose of allopurinol to potentially reduce the risk of allopurinol hypersensitivity (Stamp et al., PMID 22488501). To my knowledge, there are ...
Is there a role for regular hepatitis and TB screening in patients on chronic immunosuppressive therapy in the absence of new risk factors or exposures?
Unless there has been an interval introduction of new risk factor for TB or hepatitis B, there is no need to screen annually and baseline testing is adequate.
How would you approach refractory gangrenous Raynaud's secondary to type one cryoglobulins?
Type I cryoglobulins are monoclonal immunoglobulins, and typically occur in the context of a hematologic disorder such as MGUS, multiple myeloma, Waldenstrom macroglobulinemia, or lymphoma. Vascular occlusions due to the cryoglobulins may occur and lead to digital ischemia.The patient should be eval...