Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What is your preferred treatment for refractory warm autoimmune hemolytic anemia with autoimmune neutropenia?
For immunomodulation, have you trialed IVIG? If not, this would be worth a trial. For immunosuppression, I prefer to utilize a more T cell-directed agent after failure of steroids/rituximab. Thus, a trial of MMF or cyclophosphamide may be reasonable. I think MMF may take too long to work in a situat...
How do you approach management of bone marrow involvement in sarcoidosis?
Monoclonal TNF inhibition would be an option as it is less likely to cause cytopenias and has shown some effectiveness in extrapulmonary Sarcoid. I have 2 patients who have anecdotally who have done well in the past.
How would you approach the management of HLA-B27-associated recurrent uveitis and inflammatory back pain with a recent history of melanoma?
This is a very practical question (and challenging to answer succinctly as well!). Like many scenarios seen in clinical practice, there is unfortunately less data in the literature than we would like to guide us here. While decent data exists on the risk of incident cancer following exposure to biol...
How would you approach a patient with SLE and stage 4 LN who presents with persistent significant elevation in ESR, CRP and dsDNA despite improvement of symptoms and resolution of proteinuria on MMF and HCQ?
Normalization of proteinuria in patients with class IV lupus nephritis (diffuse proliferative LN) is considered "clinical renal remission." However, these patients have approximately a 50% likelihood of having ongoing pathologic inflammation on renal biopsy. I would not recommend rebiopsy in this si...
Is it safe to continue azathioprine in a patient with severe bilateral panuveitis (thought to be related to sarcoidosis) and benign ethnic neutropenia, given worsening neutropenia since starting the medication, or should an alternative immunosuppressive agent be considered?
In this case, I would consider stopping azathioprine and switching to an alternative medication, such as an anti-TNF agent. Although not a large drop in the PMN, azathioprine is known to cause leukopenia, and in a patient with known neutropenia, extra precaution should be taken. In the case of uveit...
How do you discuss harms of MGUS screening with other medical providers?
I understand the intent of the question, but - as always - real life is more complicated. I agree that the evidence for screening completely healthy patients for MGUS does not currently exist. But, for patients with unexplained pertinent lab/imaging findings or symptoms, it's not unreasonable. In th...
Do you repeat antiphospholipid antibody testing in a patient that previously met criteria for APLS?
I would repeat APL Ab testing if I am trying to risk stratify a patient in preparation for pregnancy or surgery, for example. In some cases (see a recently posted question about stopping anticoagulation in people with prior APLS history), I would also consider rechecking if I am thinking about disco...
Would you start anabolic agents for osteoporotic hip fracture healing?
There are two relatively well-done trials for tptd for fracture healing of the proximal femur. There was a Phase 3 trial for femoral neck fractures. The FDA made it quite complicated and demanded 2 separate trials of 1,200 patients each. The trials were 3 years in duration with many difficult outcom...
In patients with severe osteoarthritis, can elevated alkaline phosphatase levels be attributed to increased bone turnover from advanced joint degeneration?
Unlikely. Other potential sources require investigation. At the very least, explore alk phos fractions/isotopes, parathormone and vitamin D levels.
Do you recommend avoidance of occupational/environmental exposures in patients with pulmonary sarcoidosis?
The best assessment of occupational exposures associated with pulmonary sarcoidosis comes from A Case Controlled Etiologic Study of Sarcoidosis (ACESS). This is nicely summarized in a state-of-the-art article that lists occupations and exposures with both positive and negative associations between o...