Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you send an antiphospholipid antibody panel routinely for all patients with an unprovoked thrombus?
Yes. My own practice is to perform testing for antiphospholipid antibodies in all patients with unprovoked VTE and also in patients with arterial thrombosis. Testing should include assays for lupus anticoagulant, anti-cardiolipin antibodies (IgG and IgM), and anti-beta 2 glycoprotein I antibodies (I...
How do you counsel patients regarding the cardiovascular risk of febuxostat?
We understand that gout is a very inflammatory state and in general that inflammatory states can be a risk factor for cardiovascular disease. Although studies such as this have shown an increased all cause and cardiovascular mortality in febuxostat group compared to allopurinol group, it is importan...
How do you approach the use of steroids for active muscle disease in patients with scleroderma-myositis overlap syndromes?
For patients with mild myopathy (mild weakness and CPK elevation), I tend to avoid steroids altogether if I can and just treat them with other therapy (like MMF or MTX). For patients with severe myopathy, particularly if they are very weak or have oropharyngeal weakness and at risk for aspiration, I...
How would you treat a poorly controlled seronegative RA patient who is steroid dependent and is on azathioprine for autoimmune hepatitis?
I would add a biologic agent, likely a TNF inhibitor or abatacept. As with any patient with active RA, it would be important to add therapy that controls their disease activity, as well as allowing them to reduce or preferentially discontinue steroids. I would avoid other agents with known risk for ...
How do you counsel young adults with antibody-negative necrotizing myopathy on prognosis and long-term monitoring/treatment?
The first step is to rule out other conditions that are associated with necrotizing myopathy, that can affect treatment and prognosis, like malignancy, thyroid disease, or genetic muscle diseases. History, physical exam, basic laboratory work-up, family history, age-appropriate malignancy screening,...
What is the role for angiography in the workup of digital ischemia?
Digital ischemia is an especially serious complication in patients with rheumatic disease, particularly scleroderma but can also be a feature of lupus, vasculitis (ANCA associated, PAN), antiphospholipid syndrome, and rheumatoid vasculitis, among others.The presence of digital pain with permanent/pe...
Do you routinely obtain a chest x-ray prior to initiating anti-TNF or other biologic therapy?
I don't routinely order a chest x-ray in patients with negative quantiferon (or other latent TB testing such as the T-spot) before starting biologics. The chest x-ray is much less specific for latent TB, particularly in the United States where TB is not endemic. Patients may have granulomas or other...
What is your preferred approach for patients with anti-phospholipid syndrome with recurrent thrombosis on coumadin and LMWH?
This is a difficult condition to manage and personalized approach/risk stratification is key. There are several potential considerations:Warfarin therapy could be intensified, anti-platelet agents could be considered (although not in combination with LMWH).For patients with an underlying autoimmune ...
How would you approach treatment for fulminant RA-associated ILD?
Even though this hypothetical patient has tolerated methotrexate (MTX), I would probably stop it since MTX can directly scar lung parenchyma and continuation of it may confuse the clinical picture. The data for adverse lung toxicity with TNFi drugs is less clear, so I would consider maintaining it. ...
In patients who develop a VTE, what conditions do you consider as persistent, provoking risk factors, and at what point are they controlled enough to stop anticoagulation?
Not a lot of controlled trials that address each situation so we rely on expert consensus and judgement, and more importantly, balancing the risk of hemorrhage vs thrombosis. ASH guidelines define chronic persistent risk factors as 1) Active cancer (e.g., ongoing chemotherapy; recurrent or progressi...