Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to management of elevated liver enzymes in patients who recently started treatment with tocilizumab?
This is an important concept because anyone using tocilizumab will eventually wrestle with this question. The question, though, does not tell you whether this is the first time a practitioner sees the liver enzyme elevation, or how high the liver enzymes rose. Since everyone should have had a lipid ...
How would you approach the treatment of a patient who, during a hospitalization, was initially diagnosed with TTP and treated with PLEX with good response, but renal biopsy then resulted class IV LN along with changes of thrombotic microangiopathy?
This is a challenging scenario; the literature consists of case reports and case series. In clinical practice, combining PLEX with cyclophosphamide or Rituximab is a possibility.I was recently involved in a case of an SLE patient with refractory TTP (no nephritis) where Caplacizumab (Scully et al.,P...
What is your approach to the use of NSAIDs in patients with a history of gastric sleeve/bypass?
The use of nonsteroidal anti-inflammatory drugs in someone with a history of gastric bypass and/or sleeve surgery is risk prohibitive. Not only is there a risk of gastrointestinal bleeding, but more importantly, there can be effects on the previous surgical, anastomosis, and other untoward effects. ...
How do you approach recurrent costochondritis in an SLE patient with nephritis who is otherwise controlled on MMF and HCQ but can't take NSAIDs?
I do the following: I reassure them it is not cardiac or pulmonary. If I'm not 100% sure, then I send to cardiology (especially in my high-risk patients) because patients can occasionally chest wall tenderness for non-musculoskeletal chest pain. Ask them to work on proper posture (I'm convinced tha...
What treatment would you use in a patient with osteoporosis on denosumab for 10 years who develops ONJ at a site of an old implant?
A bone formative agent as teriparatide.
When do you consider stopping denosumab when a patient with osteoporosis is otherwise tolerating it without issues?
This is a matter of "style" more than anything. I continue Prolia and have many patients now exceeding 10 years - up to12 years, without any apparent safety issues. I realize we are in a "data-free" zone after 10 years, but as rheumatologists, we are frequently giving monoclonal antibodies for perio...
When is the index of suspicion high for paraneoplastic systemic sclerosis in terms of clinical and serological presentation and how will you work it up?
This is a great question. Data on the risk for malignancy in newly diagnosed scleroderma patients has been emerging for the past 10 years or so. To date, it appears that the strongest risk factors may be autoantibody with RNA polymerase 3 antibodies showing consistent increase in risk amongst sclero...
What is your approach to patients who present with unilateral Raynaud's?
Thank you for that excellent question! Typically, Raynaud’s phenomenon impacts multiple digits of both hands (and often feet; sometimes tip of the nose, ears, nipples) and is often symmetric in the case of primary and can be asymmetric in Secondary Raynaud’s (often sparing the thumb). In some cases,...
What is your approach to maintenance rituximab in patients with IgG4-RD?
Since patients can go into a prolonged remission after rituximab induction therapy, I tend to monitor them for signs and symptoms of recurrence before retreating with rituximab. In patients with significant damage from IgG4-RD, such as damage to pancreatic endocrine or exocrine function, I will re-t...
How do you approach using CD 19/20 levels to redose Rituximab for ANCA associated vasculitis?
In the MAINRITSAN 2 trial, a tailored rituximab regimen adapted to ANCA-positivity or ANCA-titre change and/or circulating CD19+ B cell repopulation was compared with fixed-schedule rituximab infusions.There was no significant difference in relapse rates between the fixed-dose and tailored-dose arms...