Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there a role for prednisolone over prednisone in rheumatic patients with hepatic impairment?
Yes. In general, prednisolone is preferred over prednisone in patients with significant liver disease as conversion of prednisone to its active form (prednisolone) may be impaired. The first citation below provides a great deal of information regarding the different steroid formulations.As an aside,...
How would you advise patients with known stable autoimmune thrombocytopenia regarding the Ad26.COV2.S (Johnson & Johnson/Janssen) vaccine?
For patients with autoimmune thrombocytopenia due to SLE, I favor avoiding vaccines that employ a viral vector due to concerns for viral induced lupus flare.For patients with thrombocytopenia in association with antiphospholipid antibodies, would avoid the Johnson & Johnson (as well as Astra-Zeneca)...
How do you approach the use of low-dose aspirin for primary prevention in non-pregnant patients with SLE and positive aPL antibodies, without clinical criteria for APS?
I personally do not put all asymptomatic SLE patients with aPL labs on low dose aspirin. This is a somewhat controversial topic. Most of the data we have are from observational studies and results are mixed in regards to efficacy of low dose aspirin for primary prevention in this population. SLE pat...
Do you recommend the use of dexamethasone and anakinra as upfront treatment in a pediatric patient with secondary HLH (nonrheumatic) who is too ill to tolerate etoposide?
If there is no concern for new malignancy or systemic infection, then glucocorticoids are reasonable. I use methylprednisolone up to 30 mg/kg/day (max. one gram). Anakinra is a safe and often effective therapy for secondary HLH. It is quick acting and has a short half-life so I use it early. I gener...
How do you approach treatment for arthritis associated with multicentric reticulohistiocytosis?
There are no systematic treatment studies of multicentric reticulohistiocytosis due to its rarity. There are, however, numerous case reports of TNF inhibitors used with success, frequently requiring higher doses than used for rheumatoid arthritis. As this condition is based on proliferation of osteo...
What immunosuppressive agents aside from steroids would you use to treat bronchiolitis obliterans in a patient with long-standing seropositive RA?
There is little doubt that bronchiolitis obliterans can be a devastating lung disease. Corticosteroids remain the primary anchor therapy, however, virtually all patients will require an additional agent. Rituximab has become the primary choice and there is evidence, though mostly anecdotal, that it ...
How do you approach the management of SSc-ILD in a patient on immune checkpoint therapy?
If the oncologist thinks immune checkpoint inhibitor therapy is the best treatment for the patient's cancer, we try to facilitate this. We obtain baseline pulmonary function tests and CT scans. Repeat every three months while on therapy. Usually, these patients have pulmonary involved also, in parti...
Do you treat fibromyalgia in your practice or do you refer back to PCP after ruling out autoimmune inflammatory pathology?
The problem of managing fibromyalgia has been the topic of numerous Rheumatology National meetings and more after-hours clinic gatherings. The reality centers around your desire to take care of people; clearly, this is a group of patients who need someone to provide care. Rheumatologists are exceedi...
How do you approach screening for inflammatory bowel disease prior to starting IL-17 inhibitors?
IL-17i are now widely used to treat skin psoriasis (PsO), psoriatic arthritis (PsA), and axial spondyloarthritis (SpA). Genetic and epidemiologic studies suggest the coincidence of these diseases and Crohn’s diseases (CD) as they may present concomitantly in the same patient or affect a family membe...
Is there a role for antibody testing to confirm vaccine response for patients on rituximab after COVID-19 vaccination?
It's a great question, but I do not feel that routinely performing COVID antibody testing would help in the management of these patients: We don't know how well most commercial antibody testing correlates with neutralizing antibody/immune-status (esp. if qualitative testing is performed), and I have...