Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...
Is there a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients?
There is no good-quality evidence supporting a role for nitazoxanide for treatment of norovirus gastroenteritis in immunocompromised patients. The efficacy of nitazoxanide in viral gastroenteritis is supported by a small manufacturer-sponsored randomized, double-blind trial in non-immunocompromised ...
How do you treat a patient with new class V lupus nephritis and recent hx of breast cancer on tamoxifen?
The 2024 ACR and Kidney Disease Improving Global Outcomes (KDIGO) lupus nephritis treatment recommendations are excellent, and I tend to treat my patients similarly to their recommendations.NOTE: The KDIGO guidelines are excellent! Consider downloading them.Regarding the history of breast cancer and...
Would you be comfortable combining rituximab with voclosporin in patients with lupus nephritis not responding to standard therapy?
1st: Voclosporin is standard therapy :-). I find it interesting that we often use "standard therapy" to mean "a mycophenolate analogue or cyclophosphamide (CYC)." I consider these "old therapies" that only achieve a 25% to 30% clinical remission, leaving 65% - 70% of those patients at high risk of e...
How do you manage inflammatory back pain when X-rays and MRI show no evidence of sacroiliitis?
While a normal MRI makes the diagnosis of axial spondyloarthritis unlikely, it doesn’t completely rule it out. This is specifically true in patients with inflammatory back pain or other features of spondyloarthritis. While classification criteria definitely should not be used for diagnosis, it is he...
Do you offer antibiotic therapy for patients with a chronic joint infection, with no plans for surgery, and with an open draining sinus tract?
I think this depends on (1) the organism, (2) the host - if he/she is immunocompromised or not, and (3) if the patient is symptomatic. Generally, if the patient has a draining sinus tract that is stable and is not causing any fevers, chills, leukocytosis, etc., then I would favor not treating, as tr...
How do you approach the treatment of patients with Ehlers-Danlos hypermobile type with chronic muscle spasms with minimal exertion?
You accept that EDS is a genetic connective tissue disorder and not a rheumatological issue. You check hormones and vitamins to ensure they are in range: especially Mg with the cramps. Some EDS patients find working with an EDS physical therapist is beneficial: the goal being to learn how to exercis...
What is your approach to induction therapy and maintenance therapy for patients with autoimmune hepatitis?
Depending on the severity - if severe injury with jaundice, I admit for IV solumedrol. On an outpatient basis, will do prednisone 40mg daily - repeat labs in 1 week and if improved, start Imuran 2 mg/kg (up to 200 mg daily; TPMT testing has to be ok - otherwise will do MMF 500 mg daily and increase ...
How long do you continue IVIG for myositis patients in remission on that therapy?
Typical total duration of IVIG is about 1-2 years. If someone is in remission, I will decrease IVIG to 1 gm/kg monthly dose. If still in remission for 3 months, I decrease to 1 gm/kg every other month for 2 more cycles. If still in remission, you could either stop or do 1-2 doses every 3 months befo...
Do you check for JCV before starting belimumab?
No. The John Cunningham virus (JCV) is highly prevalent in adults (around 85% of us), and developing progressive multifocal leukoencephalopathy (PML) is incredibly rare in belimumab (BEL) patients. It would not change my patient management. Even if someone tested negative for JCV prior to starting ...