Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Are there particular subsets of AAV patients in which avacopan is more effective?
The following answer was jointly drafted by Dr. Peter Merkel and Dr. David Jayne:Patients in the ADVOCATE trial were stratified at entry according to time of diagnosis (new/relapsing), diagnosis (GPA/MPA), ANCA serotype (PR3/MPO), and background immunosuppressive (cyclophosphamide/rituximab) with re...
How do you approach the decision to initiate or continue bisphosphonate therapy in an older patient with significant esophageal disease or swallowing dysfunction?
Unless there are indications to turn first to non-bisphosphonate therapies, I would first consider whether the patient would be a candidate for IV bisphosphonate therapy. Many patients, even those without esophageal disease or dysphagia, find the convenience of an annual outpatient infusion appealin...
Do you routinely supplement folic acid in patients with rheumatoid arthritis who are taking sulfasalazine?
Full disclosure. I'm not a fan of SSZ in general. I think it is a relic of 20th-century rheumatology when the choices were gold, penicillamine, and a few other toxic molecules. Nonetheless, I know that there is an audience for SSZ where biological options are less readily available. In my own experi...
How do you approach evaluation of a patient referred for mononeuritis multiplex and +SSB?
Step 1: A clinical syndrome of mononeuropathy multiplex always requires an EMG study. Is the primary mechanism of the MnM axonal or demyelinating? If it is demyelinating, there are only two possible diagnoses: multifocal CIDP (Lewis Sumner syndrome, which can occur in the context of Sjogren's syndro...
Would you perform screening for pulmonary hypertension in a patient who has biopsy-proven Sjogren's but has a centromere antibody?
Generally, the risk of pulmonary hypertension in Sjogren's is low - about 2% in a recent study using RHC for diagnosis (Coppi et al., PMID 40058609). There have been no studies linking Raynaud's to pulmonary hypertension risk in Sjogren's, although this is true in systemic sclerosis. So the real que...
What factors do you consider when deciding to treat IgA nephropathy with immunosuppression in a patient with cirrhosis, given the possibility that IgA nephropathy could be secondary to cirrhosis?
Proteinuria is the most important factor here. If there is significant proteinuria (>1 g/d) and no other clear reason for it, I would treat the IgA nephropathy with immunosuppression. Secondary IgA due to cirrhosis is usually not associated with significant proteinuria.
How soon after a fracture would it be safe to start anti-resorptive therapy?
This is an important question. There is no definitive answer, and there have been no clinical or preclinical studies that demonstrate delayed healing in the presence of bisphosphonates. Personally, I favor waiting a few weeks before we start. That also gives us time to do a proper metabolic workup. ...
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.
Do you utilize cytokine panels to guide treatment of patients with EGPA?
Whether biomarkers can guide treatment decisions or predict disease relapse is a critical area of study in ANCA associated vasculitis. However, efforts to identify biomarkers that are predictive in EGPA are at an early stage currently. There have been multiple negative studies of biomarkers being ab...
What guides your choice between prophylactic, intermediate, and full therapeutic dosing of enoxaparin in a woman with APLS and prior fetal loss with no hx of thromboembolic disease?
First, it is essential to confirm that patients meet criteria for obstetric antiphospholipid antibody syndrome (OAPS), based on the 2023 ACR/EULAR classification criteria. This includes persistently positive laboratory criteria (confirmed on repeat testing >12 weeks apart), plus otherwise unexplaine...