Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In which clinical scenarios is relying on the urine protein-to-creatinine ratio as a measure of proteinuria unreliable, and interpretations should be made looking at urine protein and urine creatinine separately?
I typically only use spot UPCRs because (1) they are easy to obtain and thus trend (2) they account for BSA indirectly because it accounts for Cr excretion. The best role of urine protein measurements is really just to trend if your therapy is effective or to screen for disease. When looking at urin...
How do you choose between oral and IV cyclophosphamide for the treatment of ANCA-associated vasculitis?
When considering cyclophosphamide for induction in severe AAV, both oral and IV regimens are reasonable routes of administration. In the CYCLOPS trial (DeGroot, Ann Int Med, 2009), oral cyclophosphamide 2mg/kg/d was compared with IV CYC 15mg/kg q 2 weeks for the first three pulses, then every 3 week...
What is your approach to long-Covid/post-Covid syndrome in your practice?
Many academic medical centers, including ours, have opened post-COVID clinics, and they are not necessarily managed by rheumatologists nor perhaps they should be. I agree that the symptoms are quite similar to fibromyalgia although, true post-COVID-19 medical problems may well be inflammatory, and f...
How do you approach patients with ANCA vasculitis who had partial response, but continue to have disease activity on q 6 month maintenance rituximab and remain on steroids?
This question raises some fundamental issues about the management of patients with ANCA-associated vasculitis (as well as other vasculitides or chronic inflammatory disorders), including i) the need to consider the potential contribution of comorbidities to clinical signs or symptoms suggestive of v...
Does the presence of ANCA antibodies in patients with newly diagnosed lupus nephritis alter your approach to management?
I've never encountered this, to be honest, but I've always worried about what I would do, since a fair percentage of patients with lupus are reported to have ANCA antibodies thought to have no clinical relevance. The problem is the "pauci-immune" part of ANCA-associated GN, so that there is no "posi...
Is there a role for starting an anabolic agent in a patient that developed an atypical femoral fracture while on denosumab sooner than 6 months after the last denosumab dose?
The biology of an AFF is still being elucidated. However, there are many aspects of an AFF that are similar to a "stress fracture" in that there is a combination of osteoid and cartilage that does not fully mineralize. Fracture healing goes through a cartilaginous phase, followed by mineralization w...
What is your approach to treating severe manifestations of neuropsychiatric SLE in the setting of concomitant infection?
This is a scenario that most rheumatologists will face during their careers, and it always makes us nervous. We ask ourselves your exact question as we decide upon management.First, I cannot let this question go without making a statement about the term "neuropsychiatric SLE." I propose that this sh...
Is there a role for measuring serum mycophenolate mofetil levels (or its active metabolite) in the management of lupus nephritis?
I check MMF levels in 2 different scenarios: It helps improve adherence. If levels are undetectable, this provided an opportunity to discuss adherence with patients and to identify barriers to taking MMF more regularly without skipping doses. For patients with CKD/ESRD who are on low MMF doses and ...
Would you consider single agent TKI for patient with metastatic renal cell carcinoma who developed biopsy proven giant cell arteritis days after starting immunotherapy?
Clinicians are not infrequently in situations where we need to help guide patients along a decision pathway for which we have little data. The vasculitis in this patient obviously was a pre-existing condition. The first question I would ask is does the patient's RCC need treatment now? If favorable ...
How do you approach infused prostacyclin therapy for critical digital ischemia?
This is a great question! Critical digital ischemia (CDI) associated with Raynaud phenomenon (RP) requires urgent measures to prevent digit loss. While, thankfully this is not very common, we come across it often enough in patients with structural vascular disease (occlusive vasculopathy) superimpos...