Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What maintenance regimen do you use for a patient with lupus cerebritis?
I prefer a mycophenolate analogue (MPA, usually mycophenolate mofetil, MMF, but prefer mycophenolic acid if on a PPI, which causes reduced MMF bioavailability, or if MMF intolerant) over azathioprine (AZA) for maintenance.Reasoning is that MPAs have shown better efficacy in improving outcomes and pr...
How do you approach incidental NXP-2 antibody positivity in patients without current clinical evidence of myositis or systemic autoimmune disease?
A positive anti-NXP2 antibody in an asymptomatic patient may indicate either a false positive or a subclinical form of dermatomyositis. The initial step is to review the testing method (e.g., ELISA, immunoblot). If possible, confirm the result with a different assay, ideally immunoprecipitation, tho...
How do you approach management and monitoring of a patient with features suggestive of early or incomplete antisynthetase syndrome (mechanics hands and positive antisynthetase antibody) but no objective evidence of myositis, arthritis, or ILD at presentation?
Anti-Ha is a very rare antibody, and its positive predictive value is low, particularly when relying on line blot or multiplex bead assays. Especially in the setting of a high ANA titer, a low-level anti-Ha signal may represent cross-reactivity or a false positive, as anti-Ha antibodies are cytoplas...
Is there a difference in efficacy between steroid-sparing agents like methotrexate, mycophenolate, and azathioprine in the treatment of immune-mediated myopathies?
Currently, there is no high-quality evidence favoring one immunosuppressive agent over another in the treatment of immune-mediated myopathies, as there are no head-to-head comparative trials and most available data come from small, observational, or retrospective studies. As a result, the choice of ...
How do you approach the decision to initiate or continue bisphosphonate therapy in an older patient with significant esophageal disease or swallowing dysfunction?
Unless there are indications to turn first to non-bisphosphonate therapies, I would first consider whether the patient would be a candidate for IV bisphosphonate therapy. Many patients, even those without esophageal disease or dysphagia, find the convenience of an annual outpatient infusion appealin...
How do you treat nocturnal leg cramps?
Nocturnal leg cramps are similar to daytime leg cramps, but stretching may be less convenient to use as a remedy, as sleep can be further disrupted. Treating and preventing leg cramps typically utilizes some combination of hydration and electrolytes but sometimes, medications can help. Consider the ...
How do you approach management of a patient with coexisting psoriasis and systemic sclerosis, particularly when both active psoriasis and skin tightening are present?
It depends if both diseases are considered significant and active. If so, a JAK-inhibitor would kill two birds with one stone. JAK's are already approved for psoriatic arthritis, and there is decent data for skin psoriasis as well, on par with some of our currently FDA-approved therapies. There is s...
How do you approach diagnosis and management of orbital myositis?
Orbital myositis is an umbrella diagnosis that includes a wide range of potential underlying conditions. Patients with this presentation are often first evaluated by neuro-ophthalmology to exclude causes such as isolated orbital myositis, myasthenia gravis, thyroid eye disease, infection, and diabet...
When do you consider testing autoimmune antibodies for axonal polyneuropathies without clear etiology?
Dr. @Dr. First Last gave an excellent summary of the clinical red flags that should trigger antibody testing in polyneuropathies. I would like to highlight that not all antibodies are pathogenic or cause the same phenotypes/clinical syndromes, therefore, I would like to break it down by antibody gro...
How do you approach evaluation of a patient referred for mononeuritis multiplex and +SSB?
Step 1: A clinical syndrome of mononeuropathy multiplex always requires an EMG study. Is the primary mechanism of the MnM axonal or demyelinating? If it is demyelinating, there are only two possible diagnoses: multifocal CIDP (Lewis Sumner syndrome, which can occur in the context of Sjogren's syndro...