Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In which patients with SSc do you add anti-platelet therapy and/or statins for Raynaud's phenomenon?
We believe that platelet aggregation plays some role in the development of digital ulcers, but we don't have any trial data to support the use of antiplatelet agents. But for patients who have recurrent digital tip ulcerations despite vasodilators, I will consider the use of antiplatelet agents (81 ...
When should bone biopsy be considered to guide management in patients in whom you're differentiating osteoporosis and renal osteodystrophy?
This is a major issue in patients with advanced CKD. Definitive RCT treatment trials for osteoporosis had an inclusion criteria of a normal PTH and an exclusion criteria of elevated creatinine greater than 1.1 to 1.5 (depending on the study). Therefore, in patients with CKD 3 and more severe CKD, AN...
When would you consider use of emapalumab for HLH/MAS?
The FDA has approved emapalumab for familial HLH. For secondary HLH/MAS, I typically begin with anakinra (100 mg q 6 hrs for those 40 kg or more). If this is not enough and if CXCL9 (I send on day one to have the data available) is notably elevated, then consider adding emapalumab. Alternatively, a ...
Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?
This is (and remains) a somewhat controversial question. ANCA titers do appear to rise in anticipation of disease flares and patients with persistent titers appear to have more flares. This is especially true for PR3 ANCAs. However, the proximity of flares to rising ANCA titers is not terribly close...
Do you use IL-1 inhibitors to prevent flares of gout or CPPD in patients who experience flares despite prophylaxis with colchicine, NSAIDs, and/or low-dose prednisone?
I have used IL-1 inhibitors to control gout flares or gout flare recurrences in patients who have been refractory to standard gout flare or gout flare prophylaxis management. Likewise, on extremely rare occasions, I have used an IL-1 inhibitor for recurrent CPPD flares, though with mixed results.The...
How do you incorporate smart phone microscopy into your clinical assessment of Raynaud's?
I don’t personally use smartphone microscopy in the clinic. I use a commercially available nailfold cap device, which has associated software for analyzing the images and formulating a report that is uploaded to the patient’s medical record.
For suspected IgG4-RD, what imaging modality do you use in your practice for initial diagnostic evaluation?
Imaging is an essential component of the workup of IgG4-related disease (IgG4-RD). This is because multiorgan involvement is common, and many sites of involvement (e.g., pancreas, kidneys, blood vessels) may be entirely asymptomatic even during active disease, despite still placing the patient at hi...
Do you use naltrexone in your patients with fibromyalgia?
I do not use low-dose naltrexone as a first-line agent for patients with fibromyalgia. Well-designed RCTs (Due Bruun et al., PMID 38258677; Bested et al., PMID 38226027) have not shown significant improvements in pain or other outcomes in the overall population of patients with fibromyalgia. That sa...
What drives you to choose voclospsorin over tacrolimus given the substantially higher cost?
In a discussion of comparing voclosporin versus tacrolimus to treat LN, I would first like to address the issue of cost. As far as any individual patient, out-of-pocket expenses may be similar for these two calcineurin inhibitors since it is often covered by insurance. Additionally, Aurinia has a ve...
Do you ever combine voclosporin and belimumab in the treatment of lupus nephritis?
The combination of these two therapies has not yet been formally tested. Having said that, the combination has an appealing rationale. Immunologically, modulating T cells and B cells in LN seems likely to be efficacious. Beyond the immunology, there are other reasons that favor this combination. Voc...