Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach oral DMARD and/or biologic selection in patients with RA and a history of gastric bypass or whom are planning bariatric surgery?
Very interesting and important question. It is important to remember gastric bypass patients, depending on the type of intervention, can change the absorption of a host of medications, so it is a challenge to know if a lack of response is from poor efficacy or poor absorption, therefore poor bodily ...
How do you recommend tapering IVIG in patients whose inflammatory myositis has achieved remission?
This is a very good question without any right or wrong answer. My practice is to start tapering the IVIG 6 months after the patient has achieved clinical remission. I usually start decreasing the dose of the IVIG, but the other option is to extend the interval between the patient's infusions. The e...
How would you approach a low to moderate titer of one of the APLS antibodies in a patient with a strong family history but no personal history of thrombosis?
I would repeat these tests in about 12 weeks or so. Certain infections can transiently induce positive antiphospholipid antibodies, usually non-pathogenic, with certain exceptions.
How would you counsel a patient with active SLE on treatment, low to moderate level of one of the APLS antibodies, and remote history of provoked blood clot regarding perioperative anticoagulation?
Without knowing more specific details, my approach would be to repeat the full panel of antiphospholipid antibodies, institute treatment with HCQ if not there already, discontinue all estrogen products and counsel the patient against smoking. I would coordinate perioperative anticoagulation with a h...
Are there any major differences in clinical manifestations or autoantibody profiles in children with SLE based on ethnicity?
While there is some published data, including those from the Toronto pediatric lupus cohort (Hiraki et al., PMID 19833755), that suggest the prevalence of severe organ manifestations such as nephritis and central nervous system involvement may vary by race or ethnicity, it is difficult to know how d...
What are some explanations for the persistent renal outcome disparity gaps affecting certain minority groups of patients with pediatric SLE despite improvement in overall renal outcomes?
There are likely some genetic causes, for example, Blazer et al., PMID 33461980 have shown in a Ghanian cohort of patients with SLE that apolipoprotein 1 risk variants are associated with progressive renal failure. However, it is undeniable that in the US, children in minoritized groups are dispropo...
Do you typically see peripheral neuropathy in patients with castleman syndrome?
Castleman's is a rare disorder. It has been associated with POEMS in which severe neuropathy is part of the syndrome, but is not as common an association as myeloma. But neurologists only see the patients who have neurologic symptoms. My brief look at review articles on Castleman's suggests that POE...
Would you consider re-irradiation for recurrence of Dupuytren's Contracture?
I have, in fact, re-treated one patient about two years after the first course because some nodules were progressing. I did a limited electron field with bolus to cover just the affected area and gave 200 x 10. Things seemed to stabilize after that. I would not treat a third time, however, but I hav...
What target do you utilize in clinical practice for defining disease remission in RA?
Clinical trials have consistently shown that a treat-to-target strategy in RA achieves better outcomes than "usual care". In 2019, The American College of Rheumatology recommended four in particular: Rapid 3, DAS 28 ESR or CRP, CDAI or SDAI. Several years ago, our EMR IT team (EPIC) incorporated the...
Should we be using heart rate variability counts to gauge disease activity in persons with rheumatoid arthritis?
As noted, there is now intriguing, yet preliminary, evidence that electrical stimulation of the vagus nerve may attenuate disease activity in rheumatoid arthritis and perhaps other immune-mediated diseases. (Genovese et al., Lancet Rheum 2:e527; 2020) However, the mechanisms by which this may occur ...