Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there any concerns about using nintedanib in a patient with progressive fibrosing ILD on background mycophenolate?
The SENSCIS trial randomized patients with SSc associated ILD to Nintedanib or placebo. I think about half of these patients were still taking MMF. There was no negative signal in the group on MMF and Nintedanib, they fared at least as well as those who got Nintedanib alone and both did better than ...
What is your approach to a patient with an isolated positive rheumatoid factor, negative anti-CCP antibody, and no clinical or imaging evidence of rheumatoid arthritis?
In our clinic, we screen for hepatitis C infection in all patients with polyarthralgias especially if the RA factor is positive. A positive RA factor is non-specific and can be present in a number of chronic inflammatory conditions, autoimmune and otherwise, including alcoholic liver cirrhosis, hepa...
How do you approach the treatment of inflammatory polyarthritis in patients with myelodysplastic syndromes?
The diagnosis of a myelodysplastic syndrome (MDS) can severely limit our therapeutic choices in managing an accompanying inflammatory arthritis. Many hematologists are concerned about the possible disruption of the cytokine milieu in MDS that the addition of a biological drug may induce, and for thi...
Are there features of a nerve biopsy that help distinguish late nerve damage from vasculitis versus from a demyelinating disease?
Chronic demyelinating processes can have features of demyelination on nerve biopsy including thinly myelinated fibers, remyelinating fibers, onion bulb formation, myelinated fiber loss, and axonal regeneration, as well as variable degree of inflammation. Late vasculitic neuropathy would show axonal ...
Do you check pertussis serologies when sending labs for antiphospholipid syndrome?
The short answer is no. I do not check pertussis antibodies when evaluating patients for anti-phospholipid syndrome. A slightly longer answer is still no and, for example, a review published in the Annals of Rheumatic Diseases by Ron Asherson in 2003 discussing the relationship between various infec...
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,...