Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
How do you approach prophylaxis against glucocorticoid-induced osteoporosis in patients with end-stage renal disease on dialysis?
Treating patients with end-stage renal disease on glucocorticoids to prevent bone loss is a challenge. A patient with end-stage renal disease cannot be treated with bisphosphonates. However, denosumab the RANKL antibody has no restrictions regarding renal disease. So my suggestion is to treat a pati...
How would you approach definitive treatment of intermediate-risk prostate cancer with baseline severe (AUA >25) urinary dysfunction and severe rheumatoid arthritis?
This case presented has a number of possible variables. First, does intermediate risk in this case, Gleason 7, 3+4, or 4+3 or some other set of variables making the case intermediate risk? That might change management in terms of use of ADT use, etc. However, the question's focus appears to ask for ...
Should we recommend the COVID-19 booster vaccine to patients who had a DVT or any other complications such as hemolytic anemia or thrombocytopenia from prior vaccine doses?
There are a few case reports of VTE following COVID-19 vaccinations (approximately 10 based on my PubMed review today). However, VTE has a high incidence of 0.1% in the general population and much higher after age 45 (Mary Cushman, PMID 17433897), so determining a causal relationship between the vac...
Is there a role for immunosuppression in patients with triple positive antiphospholipid antibodies who do not meet the clinical criteria for APS?
Currently, there are no “clinical” nor “diagnostic” criteria for antiphospholipid syndrome (APS). I suspect your question refers to patients not meeting the Sapporo APS “classification criteria.”There are two primary ways that patients with triple-positive antiphospholipid antibodies (aPLs: anticard...
Do you screen for HLA-B*5801 prior to starting allopurinol in patients of backgrounds other than Asian or African-American?
The guidelines now recommend checking for the presence of the HLA-B*5801 gene only in Asians and African-Americans. However, in our clinic, we are checking for the presence of this gene on everybody who becomes a candidate to receive allopurinol, partly due to the fact that we are doing a study. Int...