Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your approach to checking IgG levels post vaccination to detect common variable immunodeficiency in patients with systemic lupus?
I recommend that this type of workup for primary immunodeficiency disorders be done as soon as a diagnosis of systemic lupus erythematosus (SLE) is made. In other words, order quantitative immunoglobulins (IgA, IgM, IgG) plus IgG subclasses during your initial workup.Reasons being: Some primary immu...
How do you approach the usage of hydroxychloroquine in patients with rheumatologic conditions and baseline cardiomyopathy or heart failure?
This is an excellent and difficult question that parallels the recent posted question about the use of hydroxychloroquine (HCQ) in someone with an abnormal visual field. There is no question that HCQ can cause cardiomyopathy. There is no question that HCQ can prolong the QT interval. Fortunately, ca...
In a patient with APS and obesity during pregnancy when switched to LMWH, do you cap the dose of dalteparin as per manufacturers labeling at 18,000U per day or do you use weight based dosing?
Hi @Dr. First Last, We use enoxaparin in our institution, but the general principle that we follow is that we do not cap LMWH dose at a set threshold. I am assuming that you're referring to thromboprophylaxis and not the management of a VTE in the past 6 months. We monitor anti-Xa levels in obese p...
What is your approach for induction therapy in dual positive anti-GBM/PR3 disease with ESRD presenting with recurrent DAH previously treated with cyclophosphamide?
Most patients who are double positive for ANCA and anti-GBM antibodies relapse with AAV rather than anti-GBM disease. The rate of relapse in single positive anti-GBM disease is very low, estimated at around 2% by some experts. This is in contrast to double-positive patients who have a relapse rate s...
What is your approach to treatment of skin-limited cryoglobulinemic vasculitis in patients with Sjogren's syndrome who lack evidence of neurological or renal involvement?
I have given this patient Rituximab prior with success.
Do you recommend patients continue folic acid for a few weeks after methotrexate discontinuation?
If Methotrexate (MTX) is being discontinued due to a side effect or toxicity, it make senses to maintain the folic acid supplementation for an additional few weeks as this may help minimize some of the unwanted symptoms such as mouth sores or nausea. If MTX is being discontinued due to lack of effic...
Do you utilize post-vaccination IgG titers to detect common variable immunodeficiency in patients who are about to start or are actively on B cell depleting therapy?
I have checked M-M-R, Td, and pneumococcal titers in patients with hx of infection and low Ig levels to see if they are making an immunological response. If any of these immune titers are low or the immunization is “due” by routine schedules, I recommend immunization and repeat testing in 6 weeks. T...
What is your approach to patients with positive anti-CCP, negative RF and tobacco use, but no current signs of active rheumatoid arthritis?
There is considerable evidence supporting a link between citrullination of proteins including the generation of CCP antibodies and smoking. A number of studies that have followed patients with this clinical phenotype have identified a heightened risk for the development of full-blown rheumatoid arth...
Do you ever taper or stop urate lowering therapy in patients who have had no gout flares and serum urate persistently below 6 mg/dl?
Part 1: Yes, but not often.Part 2: No, or extremely rarely. Read on. Urate lowering therapy (ULT) mobilizes monosodium urate (MSU) deposits and in time will resolve all of the clinical features of gout. The formation of these deposits results from sustained serum uric acid (SUA) elevations in excess...
Do you recommend chlorhexidine mouth rinse for prophylaxis against oral complications in patients undergoing dental work who are immunosuppressed?
I have not, but would defer to dental/oral medicine colleague involved in patient care.Specifically in Sjogren's, I do not recommend chlorhexidine (CH). CH (antimicrobial) is indicated for gingivitis and periodontitis. Many of the formulations contain alcohol and dye, which are irritating for dry mo...