Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you give checkpoint inhibitor therapy to a cancer patient with known dermatomyositis given the association of checkpoint inhibitor associated myocarditis, myasthenia gravis, and myositis?
I think the dermatomyositis could be more paraneoplastic that would actually benefit from controlling the cancer with ICI. I would give the treatment but I would carefully follow-up the patient for any irAEs. I will also document the rheumatological assessment, CPK, and myositis panel before startin...
How do you discern whether elevated liver enzymes are from immunotherapy versus chemotherapy when a patient is on combination chemo/immunotherapy?
There is no consensus on the best method for distinguishing the cause of elevated liver enzymes in patients being treated with ICPi's when combined with various chemotherapies. Important considerations include time of onset, severity, and presence of hepatobiliary metastases. Hepatotoxicity from ICP...
Would you consider adding voclosporin to belimumab and MMF in the setting of active proteinuria, rather than switching agents?
I would first answer the question whether the proteinuria is due to active lupus nephritis (LN) or not and whether this can be addressed by adding/increasing the dose of an ACEi/ARB. For active LN, I would switch to Voclosporin from Belimumab (continuing MMF) primarily because of concerns for toxic...
How would you differentiate new onset inflammatory myositis from paraneoplastic phenomena in a patient with recurrent uterine cancer who is taking aromatase inhibitor?
Unfortunately, distinguishing whether the patient's dermatomyositis (DM) is "idiopathic" or paraneoplastic the patient with active/recent malignancy is incredibly difficult, if not impossible. While certain myositis-specific autoantibodies (MSA) such as anti-TIF-gamma and anti-NXP-2 are associated w...
Does multi-level facet joint ankylosis without vertebral body ankylosis heighten your suspicion for axial spondyloarthritis, or can isolated facet joint ankylosis be explained by degenerative disease of the spine alone?
On x-ray or CT, if the patient is young and thin, I would certainly have a heightened suspicion for axial spondylarthritis. MRI is useful in this scenario as characteristic MRI findings of inflammation in the facet joints, such as bone marrow edema, can help distinguish from purely degenerative lesi...
What is your approach to management of ongoing scleritis in SLE despite mycophenolate?
Around 1 out of every 50 SLE patients will develop scleritis. It is essential that the rheumatologist work closely with the ophthalmologist. We (rheumatologists) are important due to our knowledge and experience with immunosuppressants, while the ophthalmologist is essential in assessing disease act...
Do you utilize ethyl chloride spray prior to steroid injections?
Ethel is not fully efficient. A spray may be inhaled and not good for the lungs long term.
What is your approach to using NIH activity and chronicity indices from renal biopsy in tailoring immunosuppression to a patient with new lupus nephritis?
I find the NIH activity and chronicity extremely valuable in LN management. If a patient has a high AI, I’m much more likely to be aggressive with corticosteroids to help stop the inflammation in its tracks. I will, of course, use a concomitant immunosuppressive/immunomodulatory agent as well (we no...
Do you continue to routinely screen for renal involvement in a patient with established Sjogren's syndrome who otherwise has only sicca symptoms?
In an article published in Rheumatology and Therapy in December 2021 titled Renal Disease in Primary Sjogren's syndrome. The authors encouraged yearly screening for renal disease as it can occur at any time during the disease course.
How do you manage calcium and vitamin D replacement in scleroderma and myositis patients with dysphagia and malabsorption?
Dietary calcium is a good choice. I recommended that my patients with dysphasia caused by scleroderma drink 2-3 glasses of skim milk daily. 8 ounces contain 300 mg of calcium which is highly bioavailable. It also provides a good source of whey protein that contains all the essential amino acids. Ano...