Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you advise a patient with quiescent vasculitis who flared with the first Covid mRNA vaccine to obtain an additional dose?
There is still much we don't know about mRNA vaccines, including the true risk of vasculitis relapse and the risk of relapses occurring with vaccine re-challenge. Relapses of vasculitis after COVID vaccination have only been reported in case report form to date. Therefore it's not possible to tell w...
Do you avoid dupilumab (IL-4 inhibition) for severe asthma in patients already taking a biologic agent for RA?
Dupixent (dupilumab) is a humanized monoclonal IgG4 antibody that works by blocking the signaling of interleukin-4 (IL-4) and interleukin-13 (IL-13). This is achieved by binding to the IL-4Rα subunit. When dupilumab occupies this subunit, it prevents IL-4 signaling via the Type I receptor and both I...
Is there any utility in checking HLA-B*5801 in our Black and Asian patients who are already tolerating allopurinol?
I don't believe there is any value in checking HLA0B*5801 once the patient has been on allopurinol therapy for several weeks or months as allergic reactions, particularly SJS and TENS, occur within the first few weeks of treatment. Further, a positive test, weeks to months after beginning allopurino...
What is your approach to treatment for a patient with progressive ILD (UIP pattern) with high titer RF but no articular symptoms?
Hello and thank you for this question. It is very important. But I need more facts to safely answer this question. My very first thought is that assessment (i.e., a thorough history and physical exam) is highly operator-dependent. In most cases, the historical and exam findings of systemic autoimmun...
How do you differentiate a lupus flare versus drug-induced lupus in patients with SLE on a drug associated with DILE?
In my experience, the most common problem is drug-induced subacute cutaneous lupus erythematosus (DI-SCLE). Many drugs can cause the new onset of SCLE or the worsening of pre-existing SCLE. The list of SCLE-causing medications is extensive, growing, and includes common medications such as proton pum...
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...