Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you consider low-dose aspirin for primary thromboprophylaxis in patients with high-risk antiphospholipid antibody profiles?
Yes, I offer low dose aspirin for patients with high titer anti phospholipid antibodies. The patients often agree unless they are concerned of increased risk of bleeding due to their profession or hobbies, such as horseback riding. I do not recall such adverse events. Nevertheless, controlled trials...
Is there a role for anti-IL6 therapy in SSc-associated ILD?
There may be a role for IL-6 inhibition for the treatment of ILD in scleroderma, but this has not been fully explored yet in clinical trials. However, the Phase II and Phase III studies of tocilizumab both suggested stabilization of FVC compared to the placebo arm. The Phase III faSScinate study inc...
Do you recommend the use of contrast to identify sacroiliitis on MRI?
If axial spondyloarthritis is suspected, and Xray of pelvis is either normal or equivocal then an MRI of SI joints is ordered to support the diagnosis of axial spondyloarthritis. The recommendation by ASAS is to order 2 sequences, T1-fat enhancing sequence, and a STIR- fat suppression sequence witho...
Do you image the spine in addition to the sacroiliac joints when you suspect axial spondyloarthritis?
This is a great question and a single correct answer does not exist. Axial SpA affecting the spine without SI joint involvement does occur but is seen in a minority of the patients. The exact prevalence is hard to determine due to lack of longitudinal data as well as significant variability in prese...
How do you approach immunosuppressive therapy in lupus-associated pulmonary arterial hypertension?
I agree with Dr. @Dr. First Last that pulmonary arterial hypertension in SLE is infrequent. In the October issue of arthritis and rheumatology, the prevalence was 2.54% in a cohort of Chinese patients. Management requires distinguishing amongst the 5 WHO groups of PAH, which in lupus includes the fo...
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...