Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach a patient with refractory polymyositis (elevated CK, weakness) despite MMF, IVIG, and moderate dose prednisone?
This is a tricky question as true "polymyositis" is exceedingly rare. In most cases, inflammatory myositis without a rash can be further categorized as an immune-mediated necrotizing myopathy, antisynthetase/overlap myositis, or IBM. So when faced with a refractory polymyositis, the first thing I wo...
Are there circumstances when you may consider imaging enthesitis in patients with psoriatic arthritis?
If you already know that there is "enthesitis", then there may not be a reason for imaging. However, there are a few circumstances to consider imaging entheses in a patient with psoriatic arthritis:1) When there is concomitant widespread pain syndrome and the enthesis is tender but not swollen on ph...
What is your approach to differentiating SLE flare in pregnancy vs pre-eclampsia?
Differentiating SLE flare in pregnancy from pre-eclampsia is challenging. This is particularly so because SLE patients have a higher risk of developing pre-eclampsia during pregnancy. There are no hard and fast rules, and often time as a provider, you are never 100% certain if a patient is having a ...
In which patients with autoimmune or inflammatory conditions are you recommending a 3rd dose of the mRNA COVID vaccine?
We found that many of the patients on immune suppressive medications do not have an appropriate response to the initial 2 doses of mRNA COVID19 vaccines. At this point, I recommend a 3rd dose to all the patients on immune suppressive medications, prioritizing the ones with known low titers of SARS-C...
What is your approach to a patient with rheumatoid arthritis and moderate disease activity on 25 mg of PO methotrexate?
Switching to sub cu may work for low disease activity, but not moderate.
How will you use REGEN-COV (casirivimab/imdevimab-monoclonal antibody treatment recently approved under EUA as post-exposure prophylaxis for Covid) in rheumatic patients on immunosuppressive therapy?
Like most other treatments, I've tried to triage use of REGEN-COV post-exposure prophylaxis (PEP) based on the other risk factors that a patient has:The NEJM study published by O'Brien et al. PMID 34347950 did show marked benefit in REGEN-COV post-exposure prophylaxis vs. placebo in the (a) decreasi...
How do you approach treatment of osteoporosis in patients with CKD who develop a fragility fracture while on denosumab?
The only option left at this point is a PTH compound. Please it or not, it still works every time in subjects with a secondary elevation of PTH. I would try either Forteo or Tymlos for a few months and see if the patient can tolerate it and if the calcium numbers remain stable. I am not sure about r...
How are you timing the third dose of the COVID-19 mRNA vaccine in patients on rituximab?
At this point, I am advising the patients to do the 3rd vaccine at least 5 months after the previous Rituximab dose. Whenever feasible, I test them for B cell reconstitution prior to vaccination, and may delay the vaccination if B cells are undetectable.
Would you pursue temporal artery biopsy in patients with PMR who develop cranial GCA symptoms and have been on PMR dose steroids for one year?
This is a challenging question. While the literature would suggest that the rate of positive biopsies after 14 days of prednisone have similar positivity to those done before 14 days (Achkar et al., PMID 8185147, retrospective study with potential for bias), there is no data to my knowledge regardin...
What is your approach to checking serum vWF antigen levels in adult patients with CNS vasculitis for monitoring disease activity?
I never have checked them but I am aware of interest in this by the Hamburg group. (Ref) Following disease activity in CNS-V is challenging but reduction/clearing of pleocytosis is important to us. Also now being able to look at serial direct vascular wall imaging is of interest and appears to corre...