Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you start a TNF-I for seronegative non-erosive RA in a patient with positive ANA and sun sensitivity without other SLE features?
A diagnosis of "seronegative non-erosive RA" can be a valid descriptor, but in some cases, the terminology may obscure the proper diagnosis. For example, RA patients who are seronegative with erosive disease are generally grouped together with seropositive patients when it comes to making most thera...
Would you still consider durvalumab consolidation after definitive chemoradiation for patients with Stage III NSCLC who are on stable weekly methotrexate dosing for psoriasis/psoriatic arthritis?
I would. Given the (now) long-term follow up with the PACIFIC trial showing an approximately 10% improvement in 5-year survival from 33 to 43% (Spigel et al., ASCO 2021, abstract 8511), I believe the risk of psoriasis flare is acceptable. I would have a discussion ("shared decision") with the patien...
Do you have any hesitations for combining belimumab with any of the DMARDs in patients with SLE/RA overlap?
The only disease-modifying agents for rheumatic diseases (DMARDs) that I would not use with Benlysta are the Janus kinase inhibitors (tofacitinib, baricitinib, and upadacitinib), which are considered “targeted synthetic DMARDs” (Harrington). We all know these agents to be as strong as biologics. Mos...
Would you discontinue anticoagulation in patients with antiphospholipid antibody syndrome, who have a remote history of thrombotic events and are now negative for pathogenic antiphospholipid antibodies?
I would certainly consider stopping anticoagulation in selected patients after an in-depth discussion about potential risks and benefits. I would not consider stopping AC in patients with a history of recurrent events, arterial events, or multiple risk factors for thrombosis (e.g. nephrotic syndrome...
When would you consider rituximab as induction therapy in IgG4-related disease?
This is a great question, especially given concerns around rituximab in the setting of the COVID-19 pandemic. I think it is reasonable to consider starting with steroids monotherapy for non-organ threatening diseases. Rituximab can be added if the patient relapses or if there is a concern for steroi...
Would you have any hesitation to use belimumab in a patient with IgA deficiency?
For the most part, I would not have any hesitation as most patients with IgA deficiency are asymptomatic and do not experience recurrent infections. If they do have a history of recurrent sinopulmonary infections, they should be seeing an immunologist and may require IVIg depending on the severity. ...
How do you approach treating cutaneous PAN?
I've had personal experience with treating at least a dozen patients with cutaneous polyarteritis nodosa. The diagnosis was made by the clinical appearance of the lesions usually erythematous nodules that spontaneously may disappear leaving behind a livedo pattern. A biopsy of the lesion verified th...
Do you routinely monitor the QTc when adding voclosporin to hydroxychloroquine in a patient with lupus nephritis?
I approach this situation similar to any drug that can potentially prolong QTc intervals when used with hydroxychloroquine (HCQ). [see final comment at the bottom]Quick answer: No, I do not monitor ECGs (QTc) in patients taking voclosporin (VOC) plus HCQ unless they are at high risk for QTc prolonga...
Why do we not typically see features of rhabdomyolysis or acute kidney injury with idiopathic inflammatory myopathies?
Because rhabdomyolysis leading to AKI means acute massive necrosis of a large number of muscle fibers with resulting release of myoglobin In blood and precipitation of myoglobin in renal tubules, leading to tubular necrosis. This acute extensive myonecrosis typically does not occur with IIMs, with t...
Would you consider using DOACs in a young patient with SLE and Libman-Sacks endocarditis, who is negative for APS?
In this scenario, our patient with lupus is young and does not have features of APS. Nevertheless, any patient with Libman Sacks endocarditis carries a heightened risk for embolization. Regarding anticoagulation, the literature on this subject is anecdotal and conflicting with some authors recommend...