Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
For patients with SLE, is there an ANC level for which you would hold or adjust hydroxychloroquine in an asymptomatic patient?
Leukopenia most often as lymphocytopenia, of course, is not unusual in lupus. Total WBC less than 4000 is an ACR classification criteria for the disease as is ALC less than 1500 on two occasions. SLICC disease classification requires ALC less than 1000. Total WBC < 3000 generates SLEDAI points. On t...
Is there any benefit to checking serum viscosity in patients with autoimmune disease and headaches/migraines to see if aspirin or clopidogrel may be beneficial?
The serum viscosity test measures the time required for the serum to flow through a calibrated capillary tube under controlled pressure. Clinically significant elevations in viscosity (≥2.5 centipoise, normal range 1.4 - 1.8 cP) can cause symptoms and are most commonly seen in hyperviscosity syndrom...
What is the interpretation of an IGRA with positive TB wells and negative nil and negative mitogen wells?
We don't see positive controls in most clinical assays. They are run, of course, but hidden from view. The mitogen well is the positive control in the IGRAs. The mitogen used QuantiFERON-TB Gold is, I believe, PHA or phytohemagglutinin. PHA turns on T-cells to indiscriminately. If I remember my mito...
How would you approach a patient with SLE and class II LN who has persistent lupus activity and incomplete B-cell depletion on rituximab therapy?
Great question! I would first make sure that their nephritis has not evolved/progressed by rebiopsying the patient if it has been a while since their last biopsy and/or they have developed new signs/symptoms of kidney involvement since their last biopsy (such as increasing UPC, decreasing complement...
What are your preferred alternative biologic agents for Blau Syndrome when anti-TNFα therapies are contraindicated?
As is true for most of us, I have limited direct clinical experience treating patients with Blau Syndrome. I have treated members of several families and am convinced that corticosteroids are effective and fraught with long-term toxicity. As the question implies, a TNF inhibitor (specifically a mono...
What tools or disease activity markers do you find most useful in tracking disease activity in Sjogren's patients?
The frequency of monitoring depends on the patient’s phenotype. For example, in patients with evidence of immunologic activity at baseline, such as B-cell hyperactivity, hypocomplementemia, or cryoglobulinemia, labs should generally be repeated every 3 to 6 months, particularly if they have active e...
Can Dupixent (dupliumab) be safely used in patients who are taking other biologics for rheumatic disease?
This is a really broad question given how many biologics exist now, but the answer is likely yes, given its outstanding safety profile. I have used it concurrently with other biologics on many occasions without any issues so far. As concurrent use increases, we may find out more if there are any "tw...
How often do you draw screening ANAs for discoid lupus?
Because a positive ANA is associated with an increased risk of progression to SLE in patients with discoid lupus, I routinely check an ANA at the initial visit in virtually all patients. If negative, I repeat it only if new symptoms concerning systemic involvement arise (e.g., joint pain, cytopenias...
During treatment of severe osteoporosis with PTH analogs (abaloparatide), would a rise in alkaline phosphatase level >200 (in the setting of normal GGT) warrant discontinuation of medication?
During treatment with PTH analogs, it is not recommended to monitor the alkaline phosphatase but only Vitamin D and calcium every three months. The alkaline phosphatase, of course, increases with PTH analog therapy, but there is no upper limit, and the concerns about osteosarcoma have been removed f...
How do you counsel patients with dermatomyositis on sun protection?
We make sure patients know that sun exposure can trigger flares, so we strongly recommend staying out of direct sunlight between 10 AM and 4 PM, using broad spectrum, SPF30+ sunscreen daily even when indoors (as UVA can penetrate through windows), and wearing sun protective clothing (ideally UPF-rat...