Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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
In a patient who completed 5 years of oral bisphosphonate and has a T score persistently in osteoporotic range, what factors help you decide whether it is appropriate to start a drug holiday vs. switch to an alternative agent?
This is an interesting question concerning a common clinical issue. Unfortunately, I am unaware of any data (evidence-based medicine) that is helpful in answering the question. My response is thus only anecdotal. There is some good data that patients with an inadequate bone density response to three...
What is the role of kyphoplasty or vertebroplasty in patients with osteoporotic spinal fractures?
Vertebroplasty and kyphoplasty can be grouped together as vertebral augmentation. They have a single indication: To reduce pain arising from a documented vertebral fracture. Kyphoplasty has an inflatable balloon and in theory, can improve vertebral height prior to introduction of the cement. I am no...
How long do you expect gastrointestinal side effects of leflunomide to persist after stopping treatment?
Leflunomide (LEF) has a long half-lasting of about 15 days. So, when dealing with advise events such as gastrointestinal toxicity, these may persist up to several weeks following discontinuation of the drug. Simply discontinuing LEF will prove to be effective in the majority of patients with adverse...
In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?
This is a good question, especially noting the high rate of recurrent thrombotic events in non-treated patients with antiphospholipid syndrome (up to 29% if untreated, but still significant among treated patients, especially after an arterial event). Edit: to jump to the punchline, I favor adding AS...
How long would you consider the use of low-dose aspirin in a patient with SLE and high risk aPL profile (without a clinical event)?
I recommend low-dose aspirin (ASA) plus hydroxychloroquine (HCQ) to ALL my systemic lupus (SLE) patients unless they have risk factors for bleeding.I do this based upon the 2017 Italian study by Fasano et al. I explain to my patients that there are uncertainties to this recommendation and that furth...
In a patient identified as having APLS because of recurrent pregnancy loss without history of thrombosis, but now has a new DVT/PE during pregnancy despite use of enoxaparin—for how long would you recommend anticoagulation?
First, as far as I know, enoxaparin has not been proven to prevent pregnancy loss in obstetric APS. Second, we know that enoxaparin has not been shown to be as effective as heparin in preventing thrombotic events in APS. Third, the patient is pregnant, a thrombophilic state, separate from APS. All t...