Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
Would you offer palliative radiation for painful bone metastases in a patient with scleroderma?
Yes, I have treated a breast cancer patient before who had scleroderma and she really wanted to avoid mastectomy. Maybe I was just lucky, but no major skin reaction. Maybe less than average even. Her disease was not active at the time. For bone met palliation, I would use higher energy like 15X for ...
How do you counsel patients regarding the cardiovascular and cancer risks associated with tofacitinib?
In my experience, trying to discuss incidence rates and hazard ratios with patients is usually met with a response such as, “So what does this mean for me?” Translating the incidence rates into the number needed to harm (NNH) provides objective numbers which are easier for them to understand. Treati...
Do you still plan to offer tofacitinib to RA patients over 65 if they have one or more additional CV risk factors?
I would consider offering tofacitinib (or another JAK inhibitor) to patients over 65 with an additional CV risk factor, but only as a last resort after all other options have been exhausted.
How do you treat patients with sarcoid who have persistent symptoms after an initial 6 week course of corticosteroids?
The answer to this question depends on what organ(s) you are treating and how severe the manifestation(s) is/are because you must balance the risk of the treatment itself, and the risk of flare with an aggressive steroid taper. 6 weeks of steroids is not appropriate for cardiac sarcoidosis that over...
What is the difference between Multisystem Inflammatory Syndrome in Adults (MIS-A) and MAS/HLH?
Macrophage activation syndrome (MAS)/hemophagocytic lymphohistiocytosis (HLH) are cytokine storm syndromes (CSS) associated with various infections, rheumatic conditions, and hematologic malignancies (among other etiologies). Multi-system inflammatory syndrome in adults (MIS-A) is a discrete entity ...