Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach management of a patient with lower extremity ulcers from livedoid vasculopathy with a history Sjogren’s and Factor V Leiden?
Assess for additional procoagulant risk factors (smoking, phospholipid Abs, estrogen, paraprotein), and mitigate.Maximize pain management and wound care.In Sjogren's with vasculopathy, pts have responded to hydroxychloroquine, aspirin, and pentoxifylline. When lesions resolve, have continue hydroxyc...
Is concomitant use of azathioprine and febuxostat safe from a bone marrow toxicity standpoint?
No- Logan et al., PMID 31885095.See evidence. If you must use both for outside reasons- start really low and slow and monitor very very closely!
How do you manage a patient with progressive cerebellar ataxia and positive cardiolipin antibodies?
I would be very cautious attributing ataxia to the presence of ACL (even if they were persistent). While an association between ataxia and apl has been described, the differential is extremely broad and should be carefully worked up in conjunction with a neurology team. Some of the more common cause...
What is your approach to leflunomide and statin use in RA patients?
Caution is advised if leflunomide or teriflunomide must be used in patients who are currently receiving or have recently received treatment with other hepatotoxic agents, such as statins. Liver enzymes (ALT, AST, and bilirubin) should be measured prior to initiation of leflunomide/teriflunomide ther...
How do you counsel patients regarding contraception use while taking mycophenolate/mycophenolic acid?
There are some data that mycophenolate mofetil may decrease the effectiveness of oral contraceptives. In patients who are taking MMF and taking oral contraceptives as their form of contraception, an additional form of contraception is preferred. However, this is not an absolute recommendation. Mycop...
In a patient who fractures after several years of denosumab therapy, would you wait 6 months after the last denosumab injection to start an anabolic agent or could start an anabolic agent sooner?
In a patient on any antiresorptive drug who fractures, we should consider an anabolic drug. A fracture does not always mean the drug has failed but we should consider changing to an anabolic since we have good evidence that anabolics have superior fracture risk reduction. Denosumab is of course mor...
What is your approach to screening for complete heart block in an asymptomatic pregnant patient with negative SSA and positive SSB antibodies?
There are case reports of congenital heart block (CHB) due to anti-RNP antibody in anti-SSA/SSB-negative pregnant women (Izmirly et al., PMID 28709760). However, it is so rare that too many fetal heart monitoring tests would need to be done to identify these rare events. The amount of time and money...
What treatment regimen for UVA-1 have you found most helpful in treating sclerotic diseases (e.g. morphea, scleroderma)?
In our department, we have had success with the following treatment regimen with UVA-1 for sclerotic diseases. The following protocol is for full-body UVA-1 (appropriate for generalized morphea, systemic sclerosis). Low dose is considered 10-30 J/cm2, medium is 30-40 J/cm2 and high is 50-60 J/cm2. W...
Do you typically get muscle MRI in patients with symptoms of myopathy?
Not routinely, but there are some scenarios where MRI is useful. Selection of muscle to biopsy in a chronic progressive myopathy. In the past, we used to select muscles based on the degree of weakness on the MRC scale and the EMG findings. One would avoid muscles with MRC strength of 3/5 or less or...
How do you counsel patients about the malignancy risk associated with azathioprine?
Malignancy with the use of AZA (Imuran) was documented many decades ago in a renal transplant population, not in rheumatoid patients. Are they equivalent? Overall I consider Imuran a pretty safe DMARD. In fact, it can be used in pregnant patients with lupus, with mothers and babies doing just fine.