Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you use an IL-17 inhibitor for a psoriatic arthritis patient with inactive inflammatory bowel disease?
It depends on the options. While I would generally avoid using an IL-17 inhibitor in a patient with a h/o IBD, if there are no other reasonable treatment alternatives, and the IBD has been inactive for a significant period of time (a year?), then I would consider it, after a full discussion of the r...
How does a history of splenectomy alter how you counsel patients on the infection risk of TNF inhibitors or other biologics?
In general, a history of splenectomy would lead to an increased concern regarding infections with parasitemia and encapsulated organisms (particularly Strep. pneumoniae, Haemophilus influenzae type b, and Neisseria meningitides). However, I would not consider prior splenectomy an absolute contraindi...
Is nailfold capillaroscopy useful for prognostication and evaluation of disease progression in scleroderma patients?
Nailfold capillaroscopy is most commonly used for diagnostic purposes in patients with Raynaud's phenomenon (RP), but is also useful for prognostication and evaluation of disease progression in systemic sclerosis (SSc) patients.Nailfold capillaroscopy examines the terminal row of capillaries at the ...
Is nailfold capillaroscopy useful for prognostication and evaluation of disease progression in MCTD/myositis patients?
Great question for clinicians: Nailfold capillaroscopy is useful for several systemic autoimmune diseases and, not surprisingly, multiple studies have documented frequent nailfold capillary abnormalities in patients with multiple types of autoimmune myositis, including dermatomyositis (DM), anti-syn...
How do you approach a patient found to have a coronary lesion suggestive of vasculitis on coronary CT?
I am not sure what findings are considered “suggestive of vasculitis on coronary CT”. Vasculitis in the coronary arteries is quite rare but can be seen in several vasculitides. There is a big difference in seeing angiographic changes atypical for atherosclerosis (which I assume is what is meant by t...
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...