Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach dosing of anakinra in MAS?
We generally start with dosing per the rheumatology guidelines of 100 mg/day (1-2 mg/kg in children) subcutaneously. Based on case reports, if this is insufficient to control the hyperinflammation, can be increased (see Ajeganova et al., PMID 33281955).
What is your approach to using nintedanib in patients on baseline immunosuppression?
Typically I start antifibrotic therapy in a few situations: The most common reason is ILD progression despite adequate immune suppression, defined as no extra-pulmonary disease activity (usually joint disease, but can tailor according to the patient's disease/situation, such as by presence of rash, ...
How would you approach a patient who has well controlled SLE on HCQ but develops cotton wool spots on routine ophthalmologic screening?
Cotton-wool spots are estimated to occur in 10-15% of SLE patients. Etiology is either thrombotic pathology from associated APS, vasculitis or atherosclerosis. Treatment is targeted to the underlying etiology: eg anti-coagulation for APS, immunosuppression for vasculitis or minimization of atheroscl...
When prescribing hydroxychloroquine, how do you explain the mechanism of action and how this translates into clinical benefit for the patient?
1. Explaining the mechanism of action of hydroxychloroquine (HCQ) when RXing it to a patient:- Time is limited in clinical practice, and there are SO MANY positive benefits of HCQ that I do not explain the MOA except with the statement:"HCQ calms down the immune system without actually suppressing t...
How do you counsel patients regarding alcohol intake when prescribing DMARDs other than methotrexate?
I always inquire about alcohol intake before starting any drug with a known issue of hepatotoxicoty, using the “Law of Two” I learned as an intern: alcohol abusers under-report their intake by a factor of two. Assuming there is no such red flag to avoid the drug, I tell my patients that alcohol is n...
How would you manage tubulointerstitial nephritis and renal tubular acidosis (RTA) in a patient with Sjogren's who is pregnant?
The most common form or renal disease in Sjogren's (SjD) is tubulointerstitial nephritis. This may result in tubular dysfunction leading to renal tubular acidosis (RTA), most commonly type I RTA leading to hypokalemia and a non-anion gap hyperchloremic acidosis. Over time, nephrocalcinosis can occur...
What is your approach to pharmacologic treatment options in a patient with both SLE and Crohn's disease?
When someone has another systemic inflammatory disease along with SLE, I always look at the drugs that can treat both. I'd want close communication between myself and GI so they can guide me regarding the Crohn's severity and activity. If the Crohn's is moderate or worse in severity, we have azathio...
Do you recommend starting aspirin for a patient with ESKD secondary to lupus nephritis with detected antiphospholipid antibodies on pretransplant workup but no history of a thrombotic event?
I agree. I tend to favor the use of Plaquenil in these APS patients although the data is not absolute either. I noticed that hematologists favor the use of the NOAC than Coumadin, and yet thus far, it appears that Coumadin, based on published data, prevents thrombosis better than other agents.
What is your approach towards initial regimen and tapering of mycophenolate in scleroderma?
I start low and go slow to avoid diarrhea and abdominal upset. I give the patient 250 mg tablets and tell them to increase as tolerated to 1000 mg PO BID. I write Cellcept 1000 mg PO BID to the pharmacy to avoid questions. I seldom increase beyond 1000 mg PO BID because it seems like pushing the dos...
How would you approach management of active bilateral pan uveitis in patients who have a history of prior infectious uveitis?
The first step in the approach to such a patient is information gathering. What type of infection caused uveitis in the past? How and for how long was it treated? What was the ocular disease phenotype in the past, what is it now (exceeding the definition of "panuveitis"), and what evidence exists to...