Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Is there a role for IVIG in the treatment of active morphea refractory to immunosuppressive agents?
While the exact mechanism of action remains unclear, IVIg therapy has demonstrated good efficacy in several rheumatic conditions including Inflammatory myositis, refractory cutaneous lupus, and also in sclerotic conditions like Systemic sclerosis where it is believed to work by increasing regulatory...
What is your approach to workup for an underlying disorder in a patient with bilateral hip avascular necrosis?
The approach to assessing hip osteonecrosis is to address the potential causes: Is there a history of antecedent trauma? Is there a family history of osteonecrosis? Is there a history of significant alcohol use? Is there a history of recent corticosteroid use? Is there a history of pancreatitis? Is ...
Does romosozumab need to be followed immediately by an anti-resorptive agent to preserve BMD gains, or could you consider a drug holiday?
A drug holiday after romosozumab is not appropriate, since we know from the phase 2 studies that BMD rapidly declines if it is not followed by antiresorptive therapy. I suggest starting an antiresorptive agent 1 month after the last dose of romosozumab, or soon thereafter. Studies show that Dmab aft...
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...