Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you treat uveitis in a patient with a history of cutaneous T cell lymphoma?
In chronic uveitis patients where systemic therapy cannot be used, local steroid injections/implants can be useful. This question does not specify the type of uveitis, so it is difficult to answer. But in general, for anterior uveitis, sub tenon triamcinolone can be used which lasts 6 months. In oth...
Do you switch to certolizumab in RA patients who are doing well on other TNFis and planning to become pregnant?
I have not “switched” any patients who are stable and doing well on an anti-TNF agent when the issue of pregnancy arises. The risk of flare remains a concern in this situation. There is enough data-base derived information (such as the OTIS registry) to suggest safety to continue an established anti...
How would you approach localized lymphadenopathy in a patient with lupus whose symptoms are otherwise well-controlled?
Localized adenopathy in lupus is infrequent and the differential is broad including nonspecific reactive hyperplasia as part of underlying illness or local trigger, infectious (e.g., suppurative in association with staph or strep, MTB, atypical mycobacterium, fungal, etc), lymphoma (e.g., Hodgkin's ...
Are you recommending tocilizumab for any COVID-19 patients?
The utility of IL-6 receptor inhibitors in COVID-19 is controversial, and I do not recommend its routine use in COVID-19 patients at this time. Although early observational studies of IL-6 receptor inhibitors in severe COVID-19 suggested potential benefits, an early RCT of tocilizumab vs. placebo (B...
Do you find addition of quinacrine to methotrexate or mycophenolate helpful in treatment of refractory CADM?
Anti-malarials are definitely one of the options for treating the skin manifestations in CADM, but the first line drug of choice would be hydroxychloroquine either alone or in combination with other DMARDs like methotrexate. In cases of either hydroxychloroquine failure or toxicity [retinal pigmenta...
What is your approach to treatment of lupus peritonitis?
Lupus peritonitis is difficult to treat and there are no evidence-based approaches, to my knowledge. I think ruling out other causes like malignancy, infection, perforation, thrombosis, liver disease, and renal/cardiac causes, as well as malabsorption and malnutrition, is the first step. Then I ...
How do you monitor response to treatment in patients with mononeuritis multiplex secondary to vasculitis?
As the reinnervation process is slow (nerve regrowth speed estimated at 1mm/day), clinically discernible neurological improvement in vasculitic neuropathy may not be observed until weeks to months later. In addition, the full spectrum of electrophysiological abnormalities may not be seen until a few...
What treatment options are available for patients with spondyloarthritis who develop biologic-induced psoriasis?
Management of patients in these situations is quite challenging and the approach should be individualized. Biologic induced psoriasis is most commonly seen with TNF-α inhibitors as a paradoxical response. However, this has also been rarely described with other biologic agents: Interleukin-6 blockers...
How do you manage arthralgias with subclinical synovitis seen on US or MRI?
The holy grail of rheumatology is to prevent the onset of clinically apparent arthritis as most leaders in the field believe that early treatment may prevent onset of overt arthritis and lead to drug-free remission. Unfortunately, the issue is much more complex than imaging alone to define early dis...
Is there a role for G-CSF treatment for SLE patients with persistent neutropenia?
There may be a role for G-CSF for treatment of SLE-related neutropenia, though would recommend using with caution only for severe neutropenia (ANC less than 500) and at lowest dose. The use of G-CSF has been looked at in small case series over the years for both SLE patients with neutropenia and Fel...