Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Does phosphatidylserine antibody play a role in the diagnosis of antiphospholipid antibody syndrome?
While additional APLAs such as aPS/PT are being investigated for clinical relevance, to date, they are not established markers for disease. I would interpret the aforementioned paper with caution, as these antibodies were tested in individuals with known and diagnosed APS. Their role in establishing...
At what point, if at all, do you decrease the frequency of or discontinue pegloticase infusions after achieving persistently low serum urate levels?
This is one of the most frequent questions physicians have about pegloticase therapy. To review, the goal of pegloticase therapy is to manage the gout patient who has an overwhelming disease burden from deposits of MSU in joints, bone and soft tissues. Frequent flares, chronic synovitis, tophi inter...
When is a kidney biopsy warranted in a patient with possible scleroderma renal crisis?
Scleroderma renal crisis (SRC) is a relatively early complication of Systemic sclerosis that almost invariably occurs within the first five years after the onset of the disease and may even be the initial manifestation of SSc. Abrupt onset of moderate to marked hypertension and acute kidney injury w...
Is there a role for eculizumab in the management of refractory lupus nephritis?
There is no evidence of eculizumab as a treatment for lupus nephritis, yet it might be considered if complement-mediated TMA presents even as a result of SLE as a trigger if direct treatment of SLE fails to achieve clinical goals.
In an RA patient with positive RF and CCP abs who is stable on TNFi biologic, how would you approach incidentally found low titer positive DsDNA abs?
ANA and dsDNA antibodies can generally be overlooked in seropositive RA if one is planning to treat (or is treating) with TNF antagonists. There are rare instances of TNFi-induced lupus-like diseases but these are not predicted by pre-existing ANA or dsDNA antibodies.
Do you combine oral and topical NSAIDs for pain relief?
This is a challenging situation but a clinical scenario frequently faced by a practicing rheumatologist. Topical NSAIDs rarely achieve a measurable blood level, and frequently can provide good pain relief at the site of symptoms. It can be a useful way to reduce the milligram dose of an oral NSAID, ...
Would you be comfortable using a JAK inhibitor in a patient with baseline thrombocytosis?
Knowing the etiology of this patient's thrombocytosis is a critical piece of information required before determining whether a JAK- inhibitor drug could be safely prescribed. Mutations in JAK-2 are responsible for several myelodysplastic disorders, some of which present with thrombocytosis. Therefor...
How would you manage a patient with osteoporosis on denosumab who develops significant renal insufficiency where it is difficult to continue denosumab due to increased risk of hypocalcemia (i.e. eGFR in the low 20’s)?
This is an interesting question. Denosumab, unlike bisphosphonates, does not have a warning about use with renal insufficiency. However, denosumab does reduce osteoclast activity for a few weeks after the injection, and this can cause hypocalcemia in patients with renal insufficiency as these patien...
How do you approach diagnosis and treatment of HLH/MAS following CAR T-cell therapy?
I maintain that immune effector cell associated hyperinflammatory syndrome is NOT HLH. Most patients post CAR-T cell therapy fulfill the criteria for HLH even if they don’t have hyperinflammatory syndrome, so it makes diagnosis very challenging. Many patients with this “HLH-like” hyperinflammatory s...
In the setting of secondary HLH associated with initial diagnosis of lymphoma, would you adjust steroid dose and type to account for differences in HLH and lymphoma treatment protocols?
I don’t necessarily recommend changing the steroid dose, unless symptoms don’t resolve with chemotherapy. I do recommend using an etoposide-containing lymphoma therapy. Many patients will respond well to lymphoma therapy and have recurrent symptoms before the next cycle is due; in those patients, I ...