Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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 ...
What parameters would you use to decide whether to stop hydroxychloroquine in a patient whose lupus is well controlled but is found to have a prolonged QT interval on routine EKG?
This is an excellent question for which there is no one-size-fits-all answer. The first question is how prolonged the QT is, and if there is another drug they are on that is contributing to the prolonged QT. Obviously, it is important to avoid prescribing other medications that prolong the QT. It is...
In managing non-renal SLE, how do you approach choosing between belimumab and anifrolumab?
Dr. @Dr. First Last, You are asking what we are all dreaming of... personalized medicine where we could identify a patient's immunologic endotype and better choose disease-modifying drugs rather than cycling patients from one combination of drugs to another.Right now, it is a dream. With so many bio...
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...
Is it necessary to prescribe a steroid taper after two weeks of high-dose prednisone (60 mg daily)?
Interesting question. Not being an endocrinologist, I don't have the expertise to advise but the reference below makes the statement that even short-term steroids can be an issue. I suspect that if you have to stop abruptly from 60 mg daily for 2 weeks, it would probably be fine in most instances bu...