Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Would you recommend waiting for a low Vitamin D level to correct to goal prior to giving a scheduled Prolia injection when transitioning a patient from Zolendronic acid to Prolia therapy for worsening osteoporosis?
When ZA is in its early days patients had to have a D level of 15ng/ml. To be on the safe side most of us want a 25 ng/ml level which is easy to obtain.
What is your experience with using anabolic therapy for treatment of osteoporosis in patients with EtOH cirrhosis and is one agent preferred over another (PTH analogue vs Evenity)?
The approach that has been recommended may be reasonable. It is important to recognize that a bone density score consistent with osteoporosis does not necessarily mean that the patient has osteoporosis i.e. loss of mineral and matrix. Osteomalacia, a mineralization defect of the collagen elastin mat...
Are SGLT2 inhibitors contraindicated in patients with osteoporosis and history of vertebral and hip fractures?
In ovariectomized mice, the GLP-1 agonists were found to improve bone density by reducing the inflammation in the bone marrow so there is no contra-indication for a patient with osteoporosis and vertebral fractures to take this class of medications. It is the first weight loss therapy that is not as...
What is the stepwise investigation of patients suspected of inflammatory myopathy?
I have published an algorithmic approach to suspected inflammatory myopathy in Continuum Lifelong Learning in Neurology from AAN (Manousakis, PMID 36537973). Unfortunately, the article is not free, and I can't attach the algorithm in this response, because it's a PPT file. Happy to provide it upon r...
Would you add abatacept to treat active inflammatory arthritis in a patient with history of RA-ILD who is already taking mycophenolate?
Although there are no controlled trials of abatacept in RA-ILD, the current literature suggests a stabilization of ILD in RA patients and is one of my principal go-to agents for this situation. A review paper from 2021 (Vicente-Rabaneda et al., PMID 33887489) indicated abatacept was associated with ...
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...