Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you counsel your RA patients to hold their methotrexate dose for simple infections such as UTIs?
I recommend that the default position is to hold methotrexate if currently exhibiting any signs or symptoms of infections. This includes asymptomatic as well as symptomatic simple UTI. Resumption of methotrexate can occur 1 week later if restored to good health with the clearing of sx. This emphasis...
Would you consider PLEX for patients with DAH from SLE-associated capillaritis?
DAH is a severe life-threatening manifestation of SLE. Usually, patients who present with DAH have multi-organ involvement. DAH could be triggered by an underlying infection. Evaluating other potential causes of hemoptysis and pulmonary infiltrates (heart failure, endocarditis, malignancy, medicatio...
Do you change management in patients that are taking bisphosphonates and develop atrial fibrillation?
I allow bisphosphonates in patients with afib. In both the alendronate and zolendronic acid trials subanalysis revealed a minimal increase of afib but FDA review suggested both conditions occur often in the elderly and there was no causality. Our group has given several thousand infusions with no af...
What workup and initial treatment should be considered for suspected autoimmune myelofibrosis?
Autoimmune myelofibrosis is rare and most often described in association with SLE, either concomitantly or during the course of the disease, and usually with depression of one or more of the blood counts. It is a rare occurrence with the proviso that since myelofibrosis is a reactive and reversible ...
How would you approach a rising PR3 in a patient with limited GPA who is currently asymptomatic on methotrexate?
This is an important question because ANCA testing is frequently used in the monitoring of disease activity in AAV. Unfortunately, ANCA is a much better diagnostic test than a disease activity biomarker. Multiple studies have looked at the utility of ANCA in monitoring disease activity finding that ...
What is your approach in a patient who develops interstitial lung disease while on anti-TNF therapy?
I would stop the TNF antagonist and never use this class of drugs again in the patient. In fact, I generally stay away from TNF antagonists in RA patients with any sign of pre-existing lung disease. The experience of Nakashita et al., PMID 25125479 is highly informative and parallels my experience, ...
How would you manage a patient on pegloticase and immunomodulation in whom the uric acid has never dropped below 6?
Pegloticase, a PEGylated uricase enzyme infused every two weeks for gout is highly effective but highly immunogenic. Patients responsive to pegloticase typically lower their serum uric acids (SUA) to <0.1mg/dL or thereabout. The initial phase 3 studies had a primary endpoint of sustained uric acid l...
Would you stop belimumab in a patient with SLE starting ravulizumab (C5 inhibitor) for myasthenia gravis due to concern for additive immunosuppression?
This is a good question for which there is not a definitive response in the literature. Benlysta has a fairly low rate of related infections though not studied in relation to the ravulizumab. Obviously, the patient should be fully vaccinated against meningitis. I would also want to assess how well t...
How do you approach the workup for patients with hyperCKemia and positive NXP2 with no clinical symptoms?
I would approach it like any case of hyperCKemia: verify that the high CK occurred in at least two measurements 24 or more hours apart, not shortly after intense physical exercise, get a careful history and exam with special attention also to skin and nail findings. If hyperCKemia is persistent get ...
When performing salivary gland ultrasound for Sjogren's, what else do you include in the differential diagnosis?
Sarcoid Amyloid