Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
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...
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...
How would you approach a patient with newly diagnosed lupus/lupus nephritis receiving cyclophosphamide (euro lupus protocol) with active hemolysis not responding to steroids or IVIG?
Most importantly, the cause of the hemolysis must be figured out. I'd consider the following and order the following tests for each. The treatment varies depending on the cause: Autoimmune hemolytic anemia (AIHA) from SLE: assess the peripheral smear looking for spherocytes and measure direct Coomb...
How do you explain a very high positive ds-DNA antibody by Elisa but negative by IFA?
Different readouts using ELISA platforms vs Cell/organelle-based assay systems may arise due to target epitopes being more biophysically accessible in an ELISA platform than they are in whole cell/organelle preparations. As such, as outlined by Dr. @Dr. First Last, it is probably prudent to use a va...
Is there any role for administering another course of recombinant zoster vaccine (Shingrix) in a previously vaccinated patient with RA, who is in clinical remission on JAK inhibitor but has had a breakthrough shingles infection?
Dr. @Dr. First Last has provided a very complete and literate response. However, the critical word is “likely”. As with most vaccines, both the strength and the duration of response to the zoster vaccine decline with worsening levels of immunosuppression. We have increasingly adopted the practice of...