Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you advise patients who had autoimmune diseases "triggered" by COVID infections on getting COVID vaccination?
To date, it is unclear whether there is a causal link between COVID-19 and incident autoimmune disease at a rate higher than the incidence of autoimmune diseases in the general population, although, there are several case reports and case series describing new cases of autoimmune disease that began ...
What is your approach to managing abnormal lipids in a patient on tocilizumab?
This discussion would apply to treating rheumatoid arthritis with tocilizumab: A baseline lipid panel is standard of care to be drawn prior to initiation of tocilizumab therapy. If the baseline lipid panel (before therapy) were abnormal, I would initiate a discussion about changes in diet and the po...
Do you approach therapy differently for patients with a diagnosis of osteoporosis based on a fragility fracture rather than based on bone mineral density on DXA (assuming no secondary causes of osteoporosis)?
This is an interesting question but the question does not define the bone density results in the individual(s) in question with a history of a fragility fracture. There are people who sustain such fractures with normal bone densities and of course, many individuals sustain fragility fractures with l...
Do you eventually stop urate-lowering therapy in gout patients with CKD who start hemodialysis?
Hemodialysis is an extremely effective serum urate lowering therapy (ULT). As such, whether or not to keep patients on other ULT depends on average serum uric acid levels, how often a patient is having flares, etc. From what I have seen, although some patients will have increased flares in the first...
Are there scenarios where you send additional antibodies beyond anti-centromere, Scl-70, and RNA polymerase III in suspected scleroderma patients?
While these are the most common ANA subtypes in scleroderma, there are several other antibodies that are important. High titer ANA's with a speckled pattern may be U1 RNP and may be associated with overlap disease (MCTD). ANA's with a nucleolar pattern can be U3 RNP (fibrillarin), Th/To, or PM -Scl,...
What is your threshold for number of alcoholic drinks per week before reconsidering prescribing methotrexate/leflunomide?
It's a great question, and the usual practice probably depends heavily on the culture in which one trained/practices. For example, the US and UK governmental guidance are notably different in their recommendations. This contrast in attitudes is also reflected in differences in the governmental defin...
How do you treat an AAV patient with recurrent bronchial stenosis that has not responded to rituximab induction therapy and dilatations?
Difficult situation and one we have recently seen at our center in a few patients. This case brings up a few key issues in the management of ANCA-associated vasculitis: We always need to confirm the diagnosis to the best of one’s ability. Look everywhere that is logical. This is especially tough wi...
What is the risk of ILD recurrence in MDA5/Ro52 positive dermatomyositis following a lung transplantation?
The risk of ILD recurrence in MDA5/Ro52 positive dermatomyositis following a lung transplant is probably very low, although specific data is unavailable. Polymyositis was documented as the recipient diagnosis for 87 lung transplants during the time period from 1988-2022 in the United States. Dermato...
How do you approach the use of biologics in patients with a history of Guillain-Barre syndrome?
Onset of demyelinating neuropathies after TNF-inhibitor treatment has been reported in a small fraction of patients treated with these agents. Although their effects on patients with a history of GBS have not been systematically studied, TNF inhibitors are generally avoided in patients with history ...
Would you start tocilizumab in a patient with temporal arteritis and cirrhosis?
This is a challenging question as data regarding this question is lacking and the decision should be individualized to the specific presentation and through shared decision making. In general, I would consider using TCZ in such clinical situations. While TCZ can cause hepatotoxicity, it's not typic...