Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How often do you recommend ophthalmologic screening exams for patients with sarcoidosis?
The American Academy of Ophthalmology has guidelines for routine eye exams for an asymptomatic, healthy individual (not someone with sarcoidosis). These guidelines include a complete, dilated eye exam at age 40, interim exams at the discretion of the patient and one's ophthalmologist, and an exam ev...
How do you evaluate livedo reticularis (not livideo racemosa)?
Livedo reticularis appears as an interrupted vascular network on the lower limbs. One does not need to warm up the affected area in order to make this diagnosis. The response to heat usually occurs in cutis marmorata that is found in children. Livedo reticularis when it is acquired in teenage and la...
How do you approach restarting immunotherapy in a patient with metastatic melanoma who previously developed immune-mediated hepatitis (Grade 3), with liver enzymes now back to baseline levels?
I prefer to rechallenge when the irAE is back to grade 0. It depends on how long the hepatitis took to revert to a normal level. If it goes back to normal quickly (within 4 weeks), I keep patients on 8 mg methylprednisolone when rechallenging patients. If they do well, I wean them off at the second ...
What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?
Unfortunately, there is no high quality data at this point to directly answer this question but here are some options. For patients who have only been treated with oral steroids, I would first consider the addition of weekly methotrexate at a dose of between 10 - 20 mg WEEKLY with supplemental folic...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
Do you utilize soluble IL-2 receptor or ACE levels as serum biomarkers to monitor disease activity in pulmonary sarcoidosis?
I use ACE levels to monitor disease activity in patients who demonstrate elevated ACE levels at diagnosis of confirmed sarcoidosis and for which there is no other explanation for elevation of ACE. ACE normalizes with treatment and will increase again if/when the disease relapses. The literature indi...
Would you stop denosumab in a patient with chronic kidney disease if they develop asymptomatic hypocalcemia after the injection?
No. Stopping denosumab leads to rebound bone resorption and loss of all gains. The hypocalcemia indicates insufficient calcium and/or calcitriol. Calcium intake should be 1,000-1,200 mg daily from food and/or supplements in divided doses with food.
Are there instances when you consider rituximab first line in a patient with class V LN?
No, I would not. I agree with the KDIGO and ACR lupus nephritis guidelines, which state that rituximab should be reserved for refractory cases and cases where the patient is intolerant of therapies that have stronger efficacy evidence (e.g., calcineurin inhibitors, cyclophosphamide, and mycophenolat...
How do you approach dyspnea in a patient with seropositive rheumatoid arthritis with normal imaging findings but abnormal PFT findings (restriction, reduced DLCO)?
Pulmonary pathophysiological abnormalities are common in individuals with rheumatoid arthritis (RA) and respiratory symptoms. In individuals without respiratory symptoms, abnormalities may even be detected by lung function testing or high-resolution CT imaging. Any compartment of the lungs may be in...
Would you use febuxostat for an African-American patient with gout and previous cardiovascular events (stroke, MI) who tested positive for HLA-B*5801?
Well, I would certainly avoid using allopurinol. The initial CARES trial raised concerns about the safety of febuxostat, using a median dose of 40 mg. The subsequent study FAST did not show any signals of CV disease using a median dose of 80 mg. The internal validity of the study was greater in the ...