Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach immunomodulatory treatment for systemic lupus associated protein losing enteropathy (PLE) in a patient whose clinical course has been complicated by significant infection?
Lupus protein-losing enteropathy (LPLE) is a rare manifestation of systemic lupus erythematosus (SLE). Therefore, the medical evidence for the "best treatment" of LPLE is only based on anecdotal reports, case series, and retrospective reviews.Although the easy way out would be to say that a SQ or IV...
How would you approach treating a patient with Rheumatoid arthritis/Psoriatic arthritis and alcoholic cirrhosis?
The liver plays a central role in the clearance of nearly all small molecule (e.g. non-biologic) drugs. Thus, cirrhosis perturbs the clearance of these agents. Moreover, there generally is a potential deleterious effect on hepatocyte health, making these drugs unattractive from a safety perspective....
How will you approach drug sequencing in patients with PMR given the SAPHYR data?
The SAPHYR study enrolled patients with PMR who relapsed while tapering prednisone at daily doses equal to or greater than 7.5 mg. One group of patients received sarilumab 200 mg every 2 weeks along with a 14-week prednisone taper and another group of patients received a placebo along with a 52-week...
At what point do you consider a patient to have relapsing PMR?
Relapses in PMR are quite common. It is not unusual for patients to do well initially and as steroids are tapered, they start to describe a recurrence of symptoms. My concern is when these relapses occur early. For example, if they are noted as a patient tapers down from 10 mg towards 5 mg/day and r...
What baseline and ongoing testing do you recommend for patients with PMR who are going to be on a prolonged steroid taper?
My answer below is specific to patients with a definite diagnosis of PMR and does not necessarily cover diagnostic testing such as evaluation for possible mimics, which is certainly important and should include infections and malignancy in main differential, or other rheumatic diseases (RA, GCA). Va...
How do you approach an obese patient on long-term methotrexate with normal liver tests in terms of workup for underlying fatty liver?
Screen with ultrasound.
How do you manage recurrent urticarial lesions in a patient with underlying connective tissue disease that is otherwise well-controlled?
Similar to other cases of chronic urticaria - skin-directed therapy with TCS + high dose daily antihistamines (e.g. fexofenadine 180 mg bid + doxepin 10 mg qhs). Then in recalcitrant cases, you can use urticaria drugs (can go for dapsone, MTX or MMF if you want to also target underlying CTD or can g...
What treatment options do you recommend in a patient with idiopathic granulomatous mastitis that has not improved on steroids and methotrexate?
I have multiple cases of IGM that I have treated successfully and have gone into remission or at least not needing any prednisone with azathioprine monotherapy and combo methotrexate and adalimumab.
Do you recommend monitoring IgG level in patients with AAV receiving rituximab?
Yes! At the OSU Vasculitis clinic, we check IgG before every rituximab infusion. At a minimum, it must be done yearly to ensure no impending CVID or to change rituximab.
Is monitoring for fetal heart block recommended in pregnant patients with only slightly elevated SSA?
At this time, we don't have a consensus on the titer that causes heart block and how that changes across different labs. Dr. Buyon's group did present this at ACR. So I would recommend HCQ and monitoring for this patient.