Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you use colchicine for gout in patients with chronic kidney disease or end-stage renal disease on hemodialysis?
As a last resort agent and with a lot of caution. For prophylaxis, half a 0.6 mg pill two times a week, carefully monitoring CBC and CK levels. If medication interactions are of concern, then do not use. For flares, a much better alternative would be glucocorticoids or even anakinra. NSAIDs could be...
How would you treat active rheumatoid arthritis in a patient in complete response on loralatinib for stage IV ALK positive NSCLC?
I would do my best to minimize immunosuppression. I would use IL-6 or Abatacept and possibly rituximab. Have done all to minimize DMARDs and have had success with all 3.
Do you recheck screening labs (ESR, BUN/Cr, urinalysis, ANA, etc) for patients with recurrent small vessel vasculitis of unknown origin with each flare?
If the recurrences occur 6 or more months apart, I would recheck the studies to exclude SLE. If the episodes are chronic, I would recheck at least once a year for the same reason or whenever there are new suggestive symptoms of LE.
Do you continue to utilize ESR and CRP in patients on tocilizumab?
Yes, it is still worthwhile getting these tests. Anti-Il-6 therapy will reduce CRP and ESR values to very low levels, so when a result returns higher than expected, it may imply limited compliance with the drug. In some patients with very high CRP values at baseline, the CRP may take some time to re...
Are whole blood hydroxychloroquine blood levels helpful in patients taking chloroquine?
I could not find anything in the literature, but a personal communication with Dr. Michelle Petri at the Johns Hopkins Lupus Center says that the answer is, "No."
How do you approach tapering off JAK inhibitors in patients with rheumatoid arthritis who are in sustained remission?
My approach to treatment changes for RA patients who are in remission is usually not specific to the kind of medications they are on. Unless the patient has adverse events, I tend to continue the medication or combination of medications that got them into remission. As we know, RA is a chronic condi...
Are there any risk factors for IO induced rhabdomyolysis and how do you approach and manage it?
IO can affect the muscle in many ways. There is a myasthenia gravis and myositis overlap. I am not sure we know whether it is rhabdomyolysis versus a CK leak vs steroid myopathy vs muscle necrosis due to something else. Did the patient have EMG or muscle biopsy? There is a lot we do not understand a...
How do you approach methotrexate management in patients with rheumatoid arthritis and moderate NASH but no fibrosis per FibroSURE?
In this scenario of a patient with defined NASH by Fibrosure or alternative biomarker or predictive index of fibrosis, I would refer for baseline Fibroscan (transient elastography) to determine the degree of steatosis and presence/degree of fibrosis. NAFLD is common in our population with an estimat...
How would you approach an elderly patient with tibial plateau insufficiency fracture and normal DEXA?
Tibial plateau fractures are common among young individuals and often the result of trauma or injury. In the elderly, they can be related to injury but as well as poor bone strength and quality. In the aging population if DXA testing is normal and the fracture is not the result of major injury searc...
Is it safe to give radiation to a breast cancer patient with discoid lupus?
In published data with whole breast, it is well tolerated and we don’t consider this as a contraindication to BCT.