Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
How do you manage injection site reactions in patients on subcutaneous biologics such as TNF inhibitors?
Injection site reactions are not infrequent, though the majority are self-limited and do not result in discontinuation of the drug. For those uncommon few individuals whose skin lesions are more prominent and symptoms (such as pain and itch) are aggravating, I first review that they are properly sel...
How would you approach failure of maintenance therapy (Azathioprine) for PR3 positive, c-ANCA positive, pulmonary–renal vasculitis previously induced with cyclophosphamide, with a history of anaphylaxis to rituximab?
This is a challenging clinical situation with several appropriate treatment approaches as follows: Desensitization to rituximab - this would need to be done in the ICU but is effective for patients who are willing to undergo the process for whom other maintenance regimen options are suboptimal. Avac...
How long do you continue rituximab in patients with ANCA associated vasculitis who have achieved remission?
My approach is to use rituximab every 6 months for remission maintenance for at least 2 years. Past that point, a lot depends on the individual patient circumstances. For patients who have already suffered substantial organ damage, for whom another flare could be catastrophic (e.g., a patient with s...
What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?
Nonbacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks endocarditis, is a form of endocarditis characterized by the presence of sterile vegetations on cardiac valves. It is most commonly associated with systemic autoimmune conditions, notably systemic lupus erythematosus (SLE) and a...
When is it appropriate to refer a systemic sclerosis patient for bone marrow transplant evaluation?
I consider patients for referral who have early diffuse disease who have continued to progress despite standard of care therapies. I think some would argue that this may also be appropriate for early patients as first line therapy if they have high risk features for progression, but I typically will...
How do you approach sequentially tapering combination therapy (i.e., IVIG, mycophenolate, rituximab) for dermatomyositis that is in remission?
This process involves trial and error and requires collaboration between the physician and the patient to determine the most appropriate tapering strategy. My personal preference is to begin tapering medications with the highest risk of side effects. Among IVIG, mycophenolate, and rituximab, I would...
Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?
Liver elastography is a useful tool to use when assessing the potential hepatotoxicity of various drug therapies. Traditionally, methotrexate accounted for nearly all the hepatotoxicity issues that we faced; however, we can add many other drugs to that list. Virtually, every immune suppressive drug ...
What treatment regimen would you recommend for a patient with biopsy-proven giant cell arteritis and diffuse cutaneous systemic sclerosis?
This is a challenging situation in which you must weigh the well-known high risk of irreversible blindness in untreated GCA with the known increased risk (but not necessarily 100% risk) of scleroderma renal crisis with steroid exposure >=15mg (Steen and Medsger, PMID 9751093). It is important to und...
How long are cholinergic agonists such as pilocarpine required to be held before doing tear assessments (ocular scoring and Schirmer’s) and sialography/salivary collection?
Discussed this with ocular and oral colleagues in the Berkeley Sjogren's Clinic. Neither request patients be off secretagogues before testing. If the testing is normal, and there is a reason to retest, they will ask the patient to hold the medication for 12-24 hours. Ocular expert did not see much e...