Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you consider the use of rilonacept to treat refractory pericarditis in lupus?
Firstly, I have not had a truly refractory lupus pericarditis patient in a very long time. This would mean not responding to, or having intolerances to, antimalarials, MTX, mycophenolate, azathioprine, tacrolimus, IVIG, steroids, colchicine, NSAIDs, rituximab, belimumab, IVIG, and now (thank goodnes...
What is the negative predictive value of a negative extended myositis panel in dermatomyositis patients?
The short answer is "not great, but it depends" since the more nuanced answer is contingent on: the constellation of myositis-specific antibodies (MSA) included on the panel, the nitty-gritty of how the commercial lab is checking the MSA included (this detail can change between vendors, or even ...
How do you manage psoriatic arthritis in patients who are planning to start treatment with checkpoint inhibitors for underlying malignancy?
This is a very important question, and I think rheumatologists will encounter cases like this more frequently as immune checkpoint inhibitors (ICIs) are being increasingly used. Roughly, 50% of patients with co-existing autoimmune disorders and malignancies have flare-ups of their autoimmune disorde...
How do you manage recurrent inflammatory pleural effusions in lupus pleuritis?
I'll stick to the immunomodulatory treatments and not discuss thoracentesis and pleurodesis for large and recurrent effusions. (These are rarely needed anyway, and I'd get the help of a pulmonologist). There really are no large study, or evidence-based proven therapies for pleural effusions and pleu...
Is there a role for cyclophosphamide in refractory digital ischemia in patients with scleroderma?
Great question! The vascular disease in Scleroderma (Systemic sclerosis/SSc) is characterized by vasospasm, a proliferative vasculopathy with intimal hyperplasia, thrombosis and/or occlusive (fibro-obliterative) arterial disease with near blockage of the vascular lumen in many cases and impaired ang...
What is your approach to refractory erosive osteoarthritis?
Indeed, JAKi seem to have a more broadly-acting antiinflammatory/immunosuppressive activity than some of our other DMARDs and biologics particularly. I have had a patient or two with EOA who have failed JAKs, but in almost all of those patients they initially had a good response, just with subsequen...
Would you target the same hydroxychloroquine blood level for discoid lupus compared to systemic lupus?
Yes, I would. A French multicenter study (under the direction of Nathalie Costedoat-Chalumeau, MD, one of my favorite HCQ experts) assessed whole blood HCQ drug levels in 300 patients with cutaneous lupus erythematosus (CLE). There were 254 cases of chronic cutaneous lupus, 160 of which were discoid...
What workup do you do for patients who have PL-7 elevation when screening for myopathy?
In the literature, the PL-7 antibody has been associated with the antisynthetase syndrome and aside from myositis, interstitial lung disease (ILD). Patients with PL-7 autoantibodies are at high risk of ILD. Referral to pulmonary should be considered. One would also consider assessing pulmonary funct...
How do you mitigate the risk of renal crisis from corticosteroids in a patient with UCTD?
I assume that this patient with UCTD has some scleroderma features (like a scleroderma-specific antibody) that are raising the concern for a renal crisis. If the patient is in the scleroderma spectrum, there probably is some risk, albeit probably low unless they have high-risk features (early, diffu...
How do you approach the continued use of TNF inhibitors in a patient with inflammatory arthritis who develops a positive dsDNA without clinical evidence of drug-induced lupus?
This is a good question and more common than we think. Most of us are not routinely drawing dsDNA ab when the patient does not have symptoms; some reviews suggest up to 29% (see review below). I have seen this, however, and continued medication with monitoring (following dsDNA ab levels with C3 and ...