Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you manage polymyalgia rheumatica refractory to prednisone, methotrexate and tocilizumab?
Interesting situation. With PMR, the first question I continue to ask myself is - do I have the right diagnosis? This disease is always rewarding to treat whether you get the thrill of starting steroids to be the hero or starting therapy and having to reassess. You report that there are no signs of ...
How do you evaluate patients who have panuveitis without any systemic symptoms?
Although many patients with panuveitis or another anatomic subset of uveitis might have a systemic disease such as sarcoidosis, Behcet's disease, ankylosing spondylitis, or inflammatory bowel disease, often a systemic disease is not diagnosable. A thorough history is the best way to suspect a system...
Do you initiate management of new onset diabetes in a patient on immunotherapy or refer immediately to endocrinology given the risk of rapid worsening?
New onset hyperglycemia during ICPi therapy warrants careful review of potential risk factors for type 2 diabetes mellitus (T2DM) and close monitoring of symptoms and lab results to distinguish from the rare and typically more threatening checkpoint inhibitor-associated diabetes mellitus (CIADM). Ne...
What is your preferred steroid sparing therapy in a patient experiencing a severe checkpoint inhibitor toxicity and not responding to high dose IV steroids?
There are likely two different questions here: 1) For patients who have responded to steroids, but are unable to taper off (or to a minimally acceptable chronic dose), I have favored mycophenolate as a steroid sparing agent. 2) For patients with severe pneumonitis that is refractory to steroid ther...
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, ...