Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your threshold for number of alcoholic drinks per week before reconsidering prescribing methotrexate/leflunomide?
It's a great question, and the usual practice probably depends heavily on the culture in which one trained/practices. For example, the US and UK governmental guidance are notably different in their recommendations. This contrast in attitudes is also reflected in differences in the governmental defin...
How do you treat an AAV patient with recurrent bronchial stenosis that has not responded to rituximab induction therapy and dilatations?
Difficult situation and one we have recently seen at our center in a few patients. This case brings up a few key issues in the management of ANCA-associated vasculitis: We always need to confirm the diagnosis to the best of one’s ability. Look everywhere that is logical. This is especially tough wi...
What is the risk of ILD recurrence in MDA5/Ro52 positive dermatomyositis following a lung transplantation?
The risk of ILD recurrence in MDA5/Ro52 positive dermatomyositis following a lung transplant is probably very low, although specific data is unavailable. Polymyositis was documented as the recipient diagnosis for 87 lung transplants during the time period from 1988-2022 in the United States. Dermato...
How do you approach the use of biologics in patients with a history of Guillain-Barre syndrome?
Onset of demyelinating neuropathies after TNF-inhibitor treatment has been reported in a small fraction of patients treated with these agents. Although their effects on patients with a history of GBS have not been systematically studied, TNF inhibitors are generally avoided in patients with history ...
Would you start tocilizumab in a patient with temporal arteritis and cirrhosis?
This is a challenging question as data regarding this question is lacking and the decision should be individualized to the specific presentation and through shared decision making. In general, I would consider using TCZ in such clinical situations. While TCZ can cause hepatotoxicity, it's not typic...
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...