Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
In what clinical situations do you consider azathioprine for treatment of inflammatory arthritis?
Azathioprine (AZA) is among the oldest pharmacologic immunosuppressive agents in use today. Initially developed as a long-lived prodrug of 6-mercaptopurine (6-MP), it was quickly found to have a more favorable therapeutic index. Gertrude B. Elion (Winner of 1988 Nobel Prize in Medicine for “importa...
Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?
A patient with a typical clinical presentation of IMNM (muscle weakness, high levels of CPK) and positive anti-HMGCR antibodies leaves no question regarding the diagnosis, and muscle biopsy would not change management. I would reserve muscle biopsy for atypical cases (for example, positive anti-HMGC...
How do you manage a patient with giant cell arteritis treated with weekly tocilizumab and low dose glucocorticoid who develops sudden vision loss?
Fortunately, this scenario is a rare event, as most patients treated with ongoing tocilizumab (TCZ) and prednisone are at a far lower risk for developing new visual loss due to giant cell arteritis (GCA). A recent paper by Amsler et al., PMID 33752737 reviewing the risk for visual loss in patients b...
In patients with suspected relapsing polychondritis, can pain, redness, and swelling occur only with sustained pressure on the ears or nose, rather than presenting spontaneously?
Hello, That is a common complaint for patients with a particular subtype of RP. Some patients can have similar symptoms in early disease. Marcela Ferrada
What is your approach for gout flare prophylaxis in patients with diabetes and advanced CKD?
Flare prophylaxis is an essential component of gout management when initiating treatment with uric acid lowering drugs (ULD). It is proven that with initiation of uric acid lowering therapy will induce gout flares, much to the chagrin of patients and doctors alike. Further that flare prophylaxis wit...
Do you use conventional DMARDs aside from methotrexate to prevent anti-drug antibody development for patients on infliximab?
Yes, I would consider using other DMARDs aside from methotrexate (MTX) if this drug cannot be used for whatever reason. In this scenario, for patients with inflammatory arthritis such as RA or PsA, leflunomide is a reasonable alternative to MTX. Azathioprine (AZA) is another option. LEF has the adva...
What is your approach to urate lowering therapy in patient with gout who is on azathioprine (for example, for transplant), where allopurinol and febuxostat are both contraindicated?
This is unfortunately not an uncommon scenario. As mentioned in the question, xanthine oxidase inhibitors such as allopurinol and febuxostat are contraindicated in patients on azathioprine or 6-MP and using them almost always leads to cytopenias due to azathioprine/6-MP toxicity (even in low doses)....
How do you approach the management of patients with suspected membranous lupus nephritis who are found to have positive PLA2R antibodies?
In a patient with known SLE with proteinuria > 500 mg/g and (+) PLA2R antibodies in the serum, a kidney biopsy would be warranted. PLA2R staining should be performed on the kidney biopsy. PLA2R staining must co-localize on the subepithelial aspect in a granular fashion similar to IgG in PLA2R posit...
How would you approach the treatment for patients with renal-limited ANCA vasculitis who have persistent proteinuria, hematuria, and ANCA titers and have completed a steroid taper and received three doses of rituximab?
Renal limited ANCA is usually MPO associated. Isolated PR-3 involvement of the kidneys are rare. Further information is needed in making a decision for this case. We need to know when the patient was diagnosed with ANCA vasculitis. What was the Serum creatinine at presentation? When was the kidney b...
Do you recommend initiating immunosuppression and plasmapheresis in patients with dialysis dependent AKI in the setting of anti-GBM disease who do not have pulmonary involvement?
Anti-GBM disease is a rare disorder (incidence perhaps 1:1,000,000 adults/year) that is characterized as a small vessel vasculitis mediated by anti-GBM antibodies directed against the alpha-3-chain of collagen IV in basement membranes. Perhaps half of patients have disease that involves both the kid...