Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
Should all patients with suspected giant cell arteritis get a PET scan to look for large vessel disease?
PET-CT and PET-MRI can be very useful diagnostic modalities in GCA, but I do not recommend universal screening with PET scanning. The upcoming ACR/VF sponsored vasculitis guidelines will likely recommend obtaining non-invasive vascular imaging to evaluate for large vessel involvement, but the recom...
How do you weigh the risks and benefits of GLP-1 RAs in patients over age 65 specifically in regards to loss of muscle mass and osteoporosis?
This is indeed a crucial question: rapid weight loss is accompanied not only by a loss of adipose tissue but also by a loss of lean mass, including muscle and bone tissue. This must therefore be taken into account when making decisions, particularly in patients with osteoporosis, frailty, sarcopenic...